Original article
MRI characteristics of brainstem encephalitis in hand–foot–mouth disease induced by enterovirus type 71—Will different MRI manifestations be helpful for prognosis?

https://doi.org/10.1016/j.ejpn.2013.03.004Get rights and content

Abstract

The MRI characteristics of 21 HFMD patients with brainstem encephalitis resulting from EV71 infection were examined to identify lesion patterns helpful in disease classification and prognosis. The author reviewed the clinical and MRI data of 21 children with brainstem encephalitis infected during the EV71 outbreak in Hainan, China from May 2008 to September 2010. Thirteen cases of brainstem encephalitis were classified as type I based on unilateral or bilateral symmetrical patch-like hyperintense T1 and T2 MRI signals restricted to the posterior brainstem. In a significant minority of these cases (6/13), damage to the spinal ventral horn was also found. Among these 13 type I cases, 2 patients died, 7 recovered fully, and 4 suffered from various neurological sequelae. Eight cases were classified with type II brainstem encephalitis based on a vague, speckled hyperintense T1 and T2 signal pattern in the posterior brainstem. Six of these patients recovered fully, and 2 cases suffered from mild sequelae. Reexamination by MRI revealed an enduring lesion in only one type II case, restricted to the medulla oblongata. The prognosis of type II cases was better than that of type I cases. The lesion pattern revealed by MRI can distinguish type I from type II brainstem encephalitis due to EV71 infection and may prove valuable for prognosis. While lesions were usually located in the tegmental part of the brainstem in both patient groups, type I cases also demonstrated spinal, thalamic, and cortical lesions.

Introduction

Enterovirus type 71 (EV71), of the family picornaviridae, was first isolated from the feces of a nine-month infant who died of encephalitis in California, USA. Afterward, reports of EV71 inflection were published in the USA, Australia, Sweden, Japan, Bulgaria, Hungary, Hong Kong China, Malaysia, and Singapore. The peak season for EV71 infection is summer and autumn, with infants and small children the most susceptible populations. The clinical manifestations include hand–foot–mouth disease (HFMD), aseptic meningitis, encephalitis, acute flaccid paralysis, and Guillain–Barre Syndrome.1, 2 Infection may lead to potentially fatal diseases, among which brainstem encephalitis and pulmonary edema of nervous origin are the most common and severe. Few reports have systematically reviewed MR imaging manifestations and subsequent clinical outcomes of EV71-infected children to reveal lesion patterns that may aid in prognosis. The author reviewed the clinical and MRI manifestations of 21 pediatric HFMD patients with brainstem encephalitis who contracted EV71 in Hainan, China from 2008 to 2010. Retrospective examination of MRI manifestations and clinical outcomes revealed that lesion patterns distinguished patients with poor prognosis from those that recovered with relatively minor neurological sequelae.

Section snippets

Study population

This study was approved by the Human Research Committee of People's Hospital of Hainan Province, and informed consent was obtained from the legal caregiver of each participant.

The diagnosis of HFMD met the criteria outlined in the Ministry of Health of People's Republic of China, Guide to the Prevention and Control of HFMD (2008).3 Enterovirus type 71 infection was confirmed by nucleic acid tests of throat swabs, feces, and/or cerebrospinal fluid (Hainan Provincial Center for Disease Prevention

Clinical manifestations

All 21 cases reviewed in the present study were hospitalized at the Department of Pediatrics, of our hospital, from May 2008 to September 2010 during the HFMD outbreak in Hainan, China. Twelve cases were male and 9 were female. Their ages ranged from 6 to 37 months (median age, 19 months). All presented with fever but of variable severity: 37.0–38.0 °C in 4 cases, 38.1–39.0 °C in 12 cases, and >39.0 °C in 5 cases. All 21 cases (100%) showed HFMD/herpetic angina. In addition, 5 cases (24%)

Discussion

Hand–foot–mouth disease (HFMD) is most often induced by a virus from the Picornaviridae family, of which EV71 and Coxsackie virus type A16 are the most common.5 In recent years, the spread of EV71 had accelerated in the Asia-Pacific region.6, 7, 8, 9 Enterovirus type 71 infects the nervous system, causing acute aseptic meningitis, brainstem encephalitis, poliomyelitis-induced paralysis, or Guillain–Barre Syndrome, among other pathologies. It is most commonly encountered in children under 5

Acknowledgments

We would like to thank the following funding sources: Hainan Natural Science Foundation 310119, Hainan Health Institution Project 2011-22.

References (16)

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Authors contributed equally to this article.

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