Table 1 Clinical manifestations of EV-A71 infections: four stages and management
From: Cardiopulmonary failure in children infected with Enterovirus A71
Stage | Signs of cardiopulmonary involvement | Other clinical manifestations | Laboratory/exam findings | Management of CPF |
|---|---|---|---|---|
1. HFMD/ Herpangina | ➢ None | ➢ Vesicular rash on hands, elbows, feet, knees and buttocks ➢ Oral ulcers and herpangina ➢ Fever ➢ GI symptoms | ➢ Generally within normal limit | ➢ None |
2. CNS Involvement | ➢ Prehypertension (systolic pressure between 90 and 95% by age ≈ 105–115 mmHg for high risk age groups) [17] ➢ Tachycardia (resting heart rate higher than normal but < 150/min) and abnormal heart rate variability( [18] [19];) | ➢ Myoclonic jerk ➢ Meningism ➢ Ataxia, tremors ➢ Lethargy ➢ Limb weakness and Polio-like syndrome ➢ Altered mental status ➢ Generalized tonic-clonic convulsion | ➢ CSF pleocytosis ➢ MRI: high signal intensities on T2 weighted images in brainstem and spinal cord [20] | ➢ Limited fluid replacement therapy ➢ Early intubation and PPV ➢ IVIg |
3. ANS Dysregulation | ➢ Inappropriate tachycardia (resting heart rate > 150/min) ➢ Severe hypertension (systolic pressure > 95% by age ≈ 115–120 mmHg for high risk age groups) [17] ➢ Tachypnea ➢ Hemoptysis, pink frothy sputum ➢ Low Pao2: Fio2 ratio ➢ Chest radiography: PE/H | ➢ Hyperglycemia (> 150 mg/dL) ➢ Profuse sweating ➢ Cranial nerve abnormality and GCS deterioration | ➢ Hypoxemia ➢ Hyperglycemia | ➢ Intubation and PPV ➢ HFOV ➢ Milrinone |
4. CPF | ➢ Hypotension ➢ Low cardiac output ➢ Signs of poor perfusion ➢ Absence of spontaneous respiration though pulmonary edema improves | ➢ Coma, paralysis ➢ Neurological sequelae | ➢ Elevated troponin I and cardiac enzyme ➢ Lactic acidosis ➢ Poor left ventricle ejection fraction | ➢ Dopamine and epinephrine ➢ ECMO ➢ Volume expansion |