腸病毒重症案例分享
台中榮民總醫院兒童醫學部 兒童加護中心&兒童心臟科
林明志醫師
Basic Data
• 盧小妹
• Age: 11-month-old
• Gender: female
• BW 11 kg
• Height 71 cm
Chief Complaint
• Referred from a regional hospital due to frequent myoclonic jerks after HFMD
Present Illness
• HFMD with fever since Nov. 28, 2011
• Admitted to a regional hosp.
• Myoclonic jerks with lower limbs weakness noted since the night of Nov. 30, 2011
• Referred to TCVGH under the impression of EV crisis
Physical examinations
• Appearance: ill-looking, poor activity
• HR 105/min, BP 122/52, RR 40/min
• Herpangina, small vesicles over palmer sides of hands and feet
• No heart murmur, clear breathing sound
• Perfusion: normal
• Muscle power: decreased in lower limbs
Lab Data
• WBC 28900/cumm, Hgb 11.7 mg/dL, Plt 553000 / cumm, N/L 84/9
• CK 63 U/l, CKMB 17 U/l
• CRP 0.60 mg/dL
• Glucose 129 mg/dL
• BUN/Cr 7/0.1 mg/dL
• Na/K/Cl/Ca 139/3.8/107/9.2 mg/dL
Family Cluster
Hospital Course
IVIG
Propranolol (Inderal)
Hospital Course
• Persistent lower limbs weakness, poor activity and slurred speech after
transferring to the ordinary ward
• Brain MRI arranged on Dec. 6, 2011 (the 6th day of admission)
Hospital Course
• Trying to walk since Dec. 8, 2011 (the 8th day of admission)
• Activity recovered since Dec. 9, 2011 (the 9th day of admission)
• MBD at the 10th day of admission
Virology Report
• Enterovirus type 71 isolated
Discussion
Huang et al. Clin Infect Dis. 2002 Apr 1;34(7):1020-4
Discussion
Fu et al. Arch Dis Child. 2004 Apr;89(4):368-73.
EV crisis bundle care (VGHTC)
• Stage I HFMD/herpangina
– Symptomatic Tx.
• Stage II CNS involvement (jerks, weakness…..)
– PICU admission, EKG monitor, setting Arterial-Line – IVIG and propranolol if tachycardia
• Stage IIIa HTN / Pul. Edema
– Milrinone if low cardiac output – ECMO standby
– Intubation (optional)
• Stage IIIb Hypotension
– Early ECMO
– Inotropic agents? (optional)
• Stage IV convalescence
– rehabilitation
Outcome of VGHTC
• Survival rate
– 30% (1998~2000) – 77% (2000~2008)
Jan et al. Intensive Care Med. 2010 Mar;36(3):520-7.
enterovirus 71 transmission rate to household contacts
• Overall enterovirus 71 transmission rate, 52%
(176/339)
– 84% for siblings (70/83) – 83%, cousins (19/23) – 41%, parents (72/175)
– 28%, grandparents (10/36) – 26%, uncles and aunts (5/19)
Chang et al. JAMA. 2004 Jan 14;291(2):222-7.
Neurologic complications in
children with enterovirus 71
infection
Huang et al. N Engl J Med.
1999 Sep 23;341(13):936-42.
Neurologic complications
• Lethargy, sleepiness or coma
• seizure attacks, ataxia
• cranial nerve palsies
– such as abducens palsy, facial palsy, dysphagia, upward gaze and nystagmus.
• Subtle symptoms of increased sympathetic tone
– such as insomnia, profuse sweating, paralytic ileus, neurogenic bladder, panic or increased startle reflex
• Polio-like , 50% long-term sequela
Chang. Pediatr Neonatol. 2008 Aug;49(4):103-12.
Summary
• Staged approach for EV crisis
• Early recognition, the key to survival
• 轉診聯絡方式
– 兒童醫學部醫療總醫師（04-23592525 ext 8046 8146）
– 兒童加護中心 林明志醫師 （0975351218）
– 兒科急診
