Changes on Cranial MRI in Patients with Ev71-Induced Encephalomyelitis.

b. Specific testing

Currently, many techniques have been deployed such as virus isolation, antibody detection, and gene amplification testing.

PCR (Polymerase chain reaction) and RT PCR (Reverse Transcription Polymerase Chain Reaction) gene amplification techniques are most widely used because of their high sensitivity and specificity.

Gene sequencing techniques: allow identification of genotypes and subgroups.

Virus culture techniques require time and high techniques. After

culture

proceed

EV71 identification techniques include blood type confirmation.

neutralization reaction using type-specific antisera.

Techniques for detecting anti-EV71 IgM antibodies are under development, but may give false-positive results and have low positive predictive value.

Indirect immunofluorescence technique using anti-EV71 antibody gives fast results but is expensive.

single

Specimens used for etiological diagnosis include stool, throat swab, rectal swab, blister fluid, and cerebrospinal fluid. Each type of specimen has its own advantages and disadvantages. For example, stool specimens are difficult to collect, but the virus excretion time in stool is long, and the positive rate is high. Cerebrospinal fluid specimens have high diagnostic value, but

proportion

low positive due to concentration

Viruses in cerebrospinal fluid are common

short.

1.3.4. Diagnosis

According to the guidelines of the Vietnamese Ministry of Health, clinical case diagnosis is determined as follows:

Element

epidemiology: basis

at age, season,

endemic area, number

young

sick at the same time.

Clinical: typical blisters on legs, knees, buttocks, with or without fever.

in mouth, palm, sole

Definitive diagnosis: RTPCR test or virus isolation.

Differential diagnosis:

Differential diagnosis with TCM includes herpes gingivitis, aphthous stomatitis, generalized scabies, chickenpox, measles, and rubella.

In herpes gingivitis, the patient usually has fever and a pale complexion.

poisoning. Gums are often red, swollen or bleeding, with cervical lymph nodes. There are many ulcerative lesions and blisters around the mouth but no lesions on the limbs.

Aphthous stomatitis usually has extensive ulcerative lesions on the lips, tongue and oral mucosa. The lesions are painful and burning, commonly seen in older children and adults, recur many times and are usually not accompanied by systemic symptoms.

Scabies

whole body is sometimes confused with

TCM due to acne lesions

water in the hands and feet. However, patients often have severe itching and damage.

injury between fingers

Unlike TCM, chickenpox often has central lesions, concentrated in large areas of skin such as the scalp and does not have lesions on the palms and soles of the feet. Blister lesions caused by chickenpox often leave scars when healed, while lesions in TCM do not leave scars when healed.

In addition to the generalized maculopapular rash, measles patients typically present with cough, rhinorrhea, conjunctivitis, and Koplik spots on oral examination. The rash in rubella is often localized and often involves the lymph nodes behind the ear.

1.3.5. Complications and prognosis

Common complications of TCM are neurological complications,

respiratory and circulatory complications. Patients often die in the disease.

the scene of these complications. According to the World Health Organization 2011, TCM can progress rapidly within 24 to 72 hours. The two golden times of the disease are when there are mouth ulcers, rashes and when there is damage to the central nervous system, especially when detecting the time of rapid pulse, increased blood pressure plays an important role in detecting signs of pre-shock, helping to promptly treat complications, reducing mortality rate.

1.3.5.1. Neurological complications

Approximately 10-30% of hospitalized cases in EV71 outbreaks in Asia progress to neurological complications, including encephalitis, brainstem encephalitis, encephalomyelitis, meningitis, acute flaccid paralysis, , .

In TCM, complications often occur early and quickly.

Neurological complications can occur from the second day of illness, respiratory and circulatory complications can appear from the third day. EV71 tends to

causes neurological complications in the acute phase but CA16 is usually

no cause

This effect. There have been many studies on

neurological complications

EV71 syndrome has been shown to leave severe sequelae or death.

Encephalitis is an inflammatory disease process that occurs in the brain parenchyma due to many different causes. Clinically, the disease often begins

acute onset with acute encephalopathy and nervous system dysfunction

Central with different levels. Unlike other encephalitis, encephalitis lesions in TCM caused by E71 are often localized in the brainstem.

respiratory center

circulation should be young

often manifests as respiratory failure

steam

circulation after nerve injury but rarely

disorder of consciousness

severe or no disturbance of consciousness , .

Stem encephalitis is the prominent clinical feature of TCM.

severe EV71 in cases

EV71 outbreaks in Asia since

decade

90s. The most severe clinical manifestations occur when patients develop acute cardiopulmonary failure, often leading to death or leaving severe sequelae even with intensive resuscitation.

EV71 meningitis often transforms into clear meningitis, rarely seen in the context of TCM and is usually benign, completely cured without sequelae within 1 to 2 weeks.

In addition, EV71 also causes other neurological diseases such as paralysis syndrome.

Guillain-Barre syndrome, transverse myelitis, febrile seizures, syndrome

benign intracranial hypertension, myoclonus syndrome) ,.

opsoclonus

Guillain-Barre flaccid paralysis: patients develop paralysis

soft

advantage

Proximal limbs are more sensitive than distal limbs, with reduced or absent tendon reflexes.

Electrophysiological examination showed demyelination in many nerve roots.

DNT protein test is quite high. Slow recovery paralysis has

Over several months, the arms usually recover better than the legs.

Transverse myelitis: patients with simultaneous paralysis of both lower limbs or

limbs. Examination revealed lesions corresponding to certain spinal cord segments. If lesions

High spinal cord injury can cause severe respiratory and circulatory disorders and death if not resuscitated properly. MRI shows transverse spinal cord injury.

Clinical neurological complications of TCM are quite diverse, manifesting at different levels. Research on TCM patients with neurological manifestations during the 1998 epidemic in Taiwan (China)

Quoc)[48] shows, startled

floundering

(myoclonic jerk) continuous

is million

The most common neurological symptoms. Startle reflexes usually last for 12 seconds, mainly in the arms and legs, and can easily appear at the beginning of sleep or when the child is lying on his back. Increased muscle tone (manifestation of decerebrate rigidity, decerebrate rigidity) is a very severe manifestation of the disease. Consciousness disorders vary from drowsiness, lethargy to coma, convulsions. Convulsions and coma are severe signs that are often accompanied by respiratory and circulatory failure. Neurological manifestations

Other disorders include balance disorders such as restlessness and unsteadiness.

staggering, limb tremors, eyes looking up. In a study, the startle sign was found in 100% of the children who died. Rarely, nystagmus, weakness, paralysis of limbs (acute flaccid paralysis), and cranial nerve paralysis. In TCM, no cases of hemiplegia have been recorded.

Figure 1.5. Changes on brain MRI in patients with EV71 encephalomyelitis.

1.3.5.2. Cardiovascular and respiratory complications.

HFMD can cause many cardiovascular and respiratory complications such as pneumonia, respiratory failure, acute pulmonary edema, myocarditis, hypertension, heart failure, circulatory collapse... Severe HFMD often has neurological complications and after only a few hours the child shows signs of respiratory and circulatory failure.

Acute pulmonary edema is a common respiratory complication with symptoms of sudden difficulty breathing, chest retraction, increased breathing rate, more severe cases of cyanosis, yawning, pink foam coming out of the mouth or endotracheal tube, and lung sounds

ran

bilateral lung moist, chest x-ray shows opacity

butterfly wings spread two

waste

school. If the patient is not treated

early childhood

will stop breathing,

cardiac arrest and rapid death. Mechanism of respiratory complications in

TCM is still unclear, however, people have seen increased blood levels of interleukin 1,6,10 and tumor necrosis factor in these cases.

Complications of myocarditis include chest pain, discomfort, and changes in T and ST waves on the electrocardiogram. Echocardiography may show dysfunction.

left ventricular function, blood biochemistry with positive Troponin I, increased Creatinkinase (CK). More severe cases can cause shock and death. Shock in TCM can be caused by central nervous system damage or myocarditis, heart failure. In the early stages, there is increased blood pressure, in the later stages, there is shock, hypotension, purple skin, cold limbs, and severe respiratory and circulatory failure that is very difficult to recover.

Pulse and blood pressure are very valuable signs to help assess the condition.

patients and patient classification and transfer. In pediatric patients it is difficult to follow

keep track of the parameters

When severe symptoms appear, the child

need to be

Transfer to the emergency room or intensive care unit for appropriate monitoring.

Table 1.6. Definition of TCM cases and complications according to WHO recommendations

Sick

Proposed definition of clinical case

Hand, Foot and Mouth Disease

Fever with a rash of blisters on the hands and feet, with or without blisters or ulcers in the mouth. The rash is sometimes maculopapular without blisters, and may appear on the buttocks, knees, and elbows, especially in young children.

and infants.

Meningitis

sterility

Fever with headache, vomiting and meningitis. Cerebral fluid

Bone marrow has 510 leukocytes/mm3, negative bacterial culture.

Stem encephalitis

Myoclonus, ataxia, nystagmus, ophthalmoplegia and bulbar palsy, with/without MRI findings. In resource-limited settings, diagnosis of encephalitis is made when the child has persistent startles and CSF

leukocytosis

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Encephalitis

Decreased consciousness, including drowsiness, sleepiness or coma, or seizures

muscle twitching or jerking

Encephalomyelitis

Acute onset with muscle weakness, decreased reflexes, and tremor

myoclonus, unsteadiness, nystagmus, ophthalmoplegia and bulbar palsy.

Acute flaccid paralysis

Acute onset of flaccid paralysis and loss of muscle reflexes.

Mental disorder

plant economy

Sweating, purple rash, rapid heart rate, rapid breathing,

high blood pressure

Acute pulmonary edema/pulmonary hemorrhage

Dyspnea with tachycardia, tachypnea, moist rales, and pink foamy exudates progressed following autonomic dysfunction.

Chest X-ray shows bilateral pulmonary infiltration, no cardiomegaly.

Cardiopulmonary failure

Cardiopulmonary failure is defined by the presence of tachycardia, dyspnea, pulmonary edema, reduced peripheral perfusion requiring vasopressors, pulmonary congestion on X-ray, and decreased

There is myocardial contraction on the electrocardiogram.

1.3.6. Treatment and prevention of Hand, Foot and Mouth Disease

1.3.6.1. Management and treatment of TCM diseases

In the majority of cases of TCM, the disease resolves spontaneously. Only a small proportion of children with TCM develop neurological symptoms and may develop respiratory and circulatory failure. Because children at risk of severe systemic complications often have subtle clinical manifestations in the early stages of the disease, then progress very rapidly with a fulminant clinical picture, early detection and timely treatment are key to reducing mortality. The main purpose of the

Primary care doctors monitor TCM cases to detect cases early.

If the disease progresses, hospitalize the patient for close monitoring and early treatment.

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