Perspective

Every pediatrician ‘needs to be able to recognize’ AFM

Kevin Messacar
Kevin Messacar

NEW YORK — It is important that pediatricians are able to identify presenting clinical features of acute flaccid myelitis, or AFM, said Kevin Messacar, MD, pediatric infectious disease physician and researcher at Children’s Hospital Colorado and the University of Colorado.

The rare illness, which causes muscle weakness and paralysis, has been confirmed in 596 patients in the United States since the CDC began tracking it in 2014, mostly in young children. Cases have spiked in even-numbered years — for example, there were 236 confirmed cases reported in 2018 vs. 28 this year.

Messacar, who has been studying AFM since 2014, delivered remarks on the illness during a presentation at the Infectious Diseases in Children Symposium.

“Every pediatrician, in fact every health care provider, needs to be able to recognize acute flaccid myelitis in order to promptly diagnose, manage and report cases of this emerging public health threat,” he told Healio. “Through active, ongoing research efforts we are learning more and more about AFM and its causes but have much more work to do toward developing effective treatment and prevention.”

The Council of State and Territorial Epidemiologists updated the case definition of AFM in 2017. According to the update, clinicians should notify public health authorities if a patient has onset of acute flaccid limb weakness and an MRI “showing a spinal cord lesion largely restricted to gray matter, and spanning one or more vertebral segments,” or “cerebrospinal fluid with pleocytosis (CSF white blood cell count [greater than] 5 cells/mm3); CSF protein may or may not be elevated.”

Messacar noted that misdiagnosis and delayed diagnosis of AFM are concerns, with providers sometimes attributing symptoms to a “remote, musculoskeletal trauma.”

Treating AFM requires a multidisciplinary approach that may include “physical therapy, occupational therapy and speech therapy,” according to Messacar. He said there are currently no controlled studies on treatment efficacy. Previous research has suggested enterovirus infection as a potential cause of the illness.

“One of the most gratifying aspects of my work in this area has been sharing with others what we know and have learned about AFM in order to raise awareness and advocate for further work that needs to be done in this area,” Messacar said. “While no one can predict the future, patterns of seasonal biennial outbreaks of AFM in the late summer and fall every other year since 2014, which suggests we need to do everything we can to prepare for the potential of continued outbreaks — whether in 2020 or beyond.” – by Eamon Dreisbach

Reference:

CDC. AFM cases in U.S. https://www.cdc.gov/acute-flaccid-myelitis/cases-in-us.html. Accessed November 25, 2019.

Council of State and Territorial Epidemiologists. Revision to the standardized surveillance and case definition for acute flaccid myelitis. 2017. https://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2017PS/2017PSFinal/17-ID-01.pdf. Accessed November 25, 2019.

Messacar K. Acute flaccid myelitis. Presented at: Infectious Diseases in Children Symposium. Nov. 23-24; New York.

Disclosure: Messacar reports no relevant financial disclosures.

Kevin Messacar
Kevin Messacar

NEW YORK — It is important that pediatricians are able to identify presenting clinical features of acute flaccid myelitis, or AFM, said Kevin Messacar, MD, pediatric infectious disease physician and researcher at Children’s Hospital Colorado and the University of Colorado.

The rare illness, which causes muscle weakness and paralysis, has been confirmed in 596 patients in the United States since the CDC began tracking it in 2014, mostly in young children. Cases have spiked in even-numbered years — for example, there were 236 confirmed cases reported in 2018 vs. 28 this year.

Messacar, who has been studying AFM since 2014, delivered remarks on the illness during a presentation at the Infectious Diseases in Children Symposium.

“Every pediatrician, in fact every health care provider, needs to be able to recognize acute flaccid myelitis in order to promptly diagnose, manage and report cases of this emerging public health threat,” he told Healio. “Through active, ongoing research efforts we are learning more and more about AFM and its causes but have much more work to do toward developing effective treatment and prevention.”

The Council of State and Territorial Epidemiologists updated the case definition of AFM in 2017. According to the update, clinicians should notify public health authorities if a patient has onset of acute flaccid limb weakness and an MRI “showing a spinal cord lesion largely restricted to gray matter, and spanning one or more vertebral segments,” or “cerebrospinal fluid with pleocytosis (CSF white blood cell count [greater than] 5 cells/mm3); CSF protein may or may not be elevated.”

Messacar noted that misdiagnosis and delayed diagnosis of AFM are concerns, with providers sometimes attributing symptoms to a “remote, musculoskeletal trauma.”

Treating AFM requires a multidisciplinary approach that may include “physical therapy, occupational therapy and speech therapy,” according to Messacar. He said there are currently no controlled studies on treatment efficacy. Previous research has suggested enterovirus infection as a potential cause of the illness.

“One of the most gratifying aspects of my work in this area has been sharing with others what we know and have learned about AFM in order to raise awareness and advocate for further work that needs to be done in this area,” Messacar said. “While no one can predict the future, patterns of seasonal biennial outbreaks of AFM in the late summer and fall every other year since 2014, which suggests we need to do everything we can to prepare for the potential of continued outbreaks — whether in 2020 or beyond.” – by Eamon Dreisbach

Reference:

CDC. AFM cases in U.S. https://www.cdc.gov/acute-flaccid-myelitis/cases-in-us.html. Accessed November 25, 2019.

Council of State and Territorial Epidemiologists. Revision to the standardized surveillance and case definition for acute flaccid myelitis. 2017. https://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2017PS/2017PSFinal/17-ID-01.pdf. Accessed November 25, 2019.

Messacar K. Acute flaccid myelitis. Presented at: Infectious Diseases in Children Symposium. Nov. 23-24; New York.

Disclosure: Messacar reports no relevant financial disclosures.

    Perspective
    Lydia Marcus

    Lydia Marcus

    Kids who have AFM will typically present with some sort of viral illness — with fever, respiratory infection and sometimes gastrointestinal illness. Then they sometimes develop arm, leg or back pain before the weakness develops. The weakness usually develops over hours to a day or two, and is flaccid weakness as opposed to spastic weakness. It can range from mild weakness to profound weakness that also involves their respiratory muscles and the muscles that control swallowing.

    One of the major barriers we have with AFM is understanding whether we have a good treatment for it. We treat these patients typically with IV immunoglobulin (IVIG), and sometimes other immunotherapies like plasmapheresis or high-dose steroids, but we have not really shown that there is a lot of efficacy with these treatments.

    One major field is trying to understand the mechanism by which AFM occurs and what treatments might work. The CDC, and all clinicians who take care of patients with AFM, recommend treating with IVIG. Having pediatricians and other clinicians aware of this disease could mean that we are able to treat patients earlier, which could potentially improve their outcomes over the long-term.

    One question that a lot of people ask us is whether it is related to polio or not. Clinically AFM looks similar to polio in that the type of weakness is similar — it is flaccid weakness. But this is definitely not polio, and in terms of what the causes are — we are still trying to understand that.

    There is an association with enterovirus infections, but it has only been found extremely rarely in the spinal fluid of patients with AFM. Whether it is correlation or causation is one question that we have not really answered, but that is a major concern for most people who are studying AFM.

    • Lydia Marcus, MD
    • Assistant professor
      Department of pediatric neurology
      University of Alabama at Birmingham

    Disclosures: Marcus reports no relevant financial disclosures.

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