The Clinical Features Of Hand, Foot And Mouth Disease Complicated With Encephalitis In271Children

Background: Hand foot and mouth disease（HFMD a common contagious diseasethat usually affects children, is normally mild with vesicles on palms,soles and mouth butsome patients develop severe neurological complications (i.e., aseptic meningitis, acuteflaccid paralysis, and encephalitis) or systemic disease (i.e., shock and cardiac dysfunctionand pulmonary edema and hemorrhage). HFMD is caused by enteroviruses (genusEnterovirus, family Picornoviridae), particularly Coxsackie A virus, CAV-16, andEnterovirus71，EV71which are mostly transmitted by the fecal-oral route, close contactand respiratory droplets..EV71was first identified in1969in California. The genotype wasBrCr prototype. EV71has a propensity to cause neurological disease during acute infection.Children <3years of age are particularly susceptible to the most severe forms of EV71-associated neurological disease, including meningitis, brain-stem and/or cerebellarencephalitis, poliomyelitis-like paralysis and encephalomyelitis.The neurologicalcomplications of EV71infection may occasionally cause permanent paralysis ordeath.Recent outbreaks in China during the last decade and other asian countries and otherparts of europe have made EV71HMFD a pandemic. Since1997, countries of the Asia-Pacific rim have been affected by large outbreaks EV71-associated HFMD, which haveresulted in hundreds of thousands of cases and many deaths. HFMD was epidemic in chinasince2008. Sporadic epidemic or outbreaks of EV71infection had occurred inmainland of China since1995but the highly aggregated cases of rapidly fatal pediatricinfections occurred in the Fuyang2008HFMD outbreak is unprecedented..In thisreport, we analyze the clinical features of271children suffering from HMFD with encephalitis admitted to Dalian Children Hospital in Liaoning province during2010outbreakMaterials and methods: Out of593hospitalized patients with HFMD,271childrencomplicated by encephalitis were diagnosed according to the ministry of health diagnosticscriteria at Dalian children’s hospital in China from1January to December31in2010.Further, Brainstem encephalitis was classified into three grades (I, II, III) based onclinical criteria The age ranged from1month to13years.The clinical data of HFMD withencephalitis in children was collected and analyzed.Results: Of the593hospitalized patients for HFMD,271patients developedencephalitis. The number of males was181and females were90, with male to femaleratio2:1.The range of age in this study varies from1month to13years with median ageof2years. In addition, the number of patients younger than3years is158(58%).Theseason of HFMD with encephalitis was from April to December with peak in July with72(26.5%) cases registered in that month followed by August with58/271(21.4%) and June51/271(18.8%). The duration of HFMD clinical course before admission is from1-7days with mean duration of3.2days.Also,the interval of the onset of HFMD todevelopment of encephalitis is2hours to5days with mean duration of1.5days. Themean duration of hospital stay is9.8with maximum number of days32days andminimum4days. Among the clinical features,the maximum fever recorded was41℃andaverage was38.5℃and mean fever duration is3.4days.The number of patientspresenting with the neurological signs are:myoclonus (122), tremor (88), ataxia (96),headache (71), vomiting (92), lethargy (166).245patients did routine blood tests and231patients did the biochemistry tests: Glucose, Liver function tests,Cardiac enzymes, CRP.The relevant laboratory results are leucocytosis in30%cases and high LDH in54%ofcases.224patients give their consent for lumbar puncture. The maximum CSF protein is1200mg/L and maximum CSF Wbc is870×106/L. The CSF WBC and CSF Protein waselevated in83%and44%patients respectively. EV71was detected in the feces by RT-PCR test in155(57%) patients. Concerning the affiliated tests,10EEG were abnormalranging from slow wave, spike wave and spike slow wave.2ECG findings were abnormal:one premature ventricular contraction and the other one is AV block and sinusitis in5CThead scan.Among the271cases,244(90%) were brainstem encephalitis,23(8.5%)generalencephalitis or meningoencephalitis,4encephalomyelitis,32severe cases were transferred to ICU. Among the brainstem encephalitis, Grade1(235patients) and Grade2(4patients)all recovered without sequelae after treatment. Among the5patients with Grade3brainstem encephalitis, one recovered completely, one had neurological sequelae and3died. All the3fatal cases were infected with EV71.6patients relapse of encephalitisduring convalescence. Among these six patients,4were males and3patients were youngerthan3years. The mean duration for relapse in convalescent stage is17days. Two patientshave rise in CSF WBC in relapse phase. At least of one similar symptom recur inconvalescent phase.6patients also presented with pneumonia along3with bronchitis.Alsoa patient had AV block and the other one had premature ventricular contraction in thisstudy.Conclusions: The incidence of HFMD with encephalitis in males appears to be morethan in females. The season of HMFD start in late spring and peak in summer in July inDalian. The age incidence varies but most cases are under3years. Most cases of HFMDwith encephalitis involve brainstem. Blood WBC count, LDH, CSF WBC and CSFProtein seem to be elevated in HMFD encephalitis. Most patients fully recovered bytreatment,but some patients deteriorated rapidly or within3days of diagnosis leading todeaths in some cases. Grade III brainstem encephalitis has a poor prognosis and highmortality rate and risk of neurological sequelae. Some patients may relapse of encephalitisoccurring around2weeks of diagnosis HFMD encephalitis. Besides nervous system, thisdisease may affect many organs:(liver, heart, lung).The main pathogen of HFMD withencephalitis is EV71. EV71infection account for the high number of encephalitis,neurological sequelae and fatality rate among the hospitalized patients.