Further to our first posting on 29 August 1997 in which we reported two fatal cases of acute viral encephalomyelitis due to EV 71, we now report on two additional cases seen in the University Hospital, Kuala Lumpur.
Case 3: WYG, a 15 month-old Chinese boy, was unwell for 5 days before admission. He developed high fever and red spots on the palms and soles. He had cough with poor feeding and was seen by a pediatrician who made a diagnosis of viral fever. When his condition deteriorated, he was taken to the Emergency Unit of the University Hospital and was found to be tachypnoeic, sweaty, cyanosed with very poor peripheral perfusion. He was still alert and responding to his mother appropriately. A chest x'ray showed diffuse pulmonary oedema. Upon intubation, copious amounts of pink frothy secretions were obtained. He developed bradycardia and despite intervention, died two and a half hours after admission.
Case 4: KR, a 4 year-old Indian girl, had a 3 day history of fever and vomiting with associated lower limbs weakness for 2 days. When seen at the University Hospital, she was alert, fully conscious with mild neck stiffness. There was paresis of the lower limbs with absent reflexes and down-going plantar. Sensation was intact. There was transient hypertension and her clinical condition deteriorated rapidly while in the ward with the development of tachypnoea and tachycardia. The patient was intubated and copious amounts of pink frothy secretion were obtained. She developed cardiorespiratory arrest and died one hour later despite active resuscitation.
Post mortem was conducted and the pathology findings in both cases were similar to the first two cases reported earlier. In Case 3, the sections of the cerebrum did not show any significant changes. However, the section of the medulla, pons and midbrain showed extensive peri-vascular cuffing of lymphocytes around most of the blood vessels, occasional sites of neuronal early degeneration with microglial reaction, and acute inflammatory cell reaction. The heart muscle was normal. In Case 4, sections of the medulla and cervical spinal cord showed widespread inflammation with perivascular lymphocytic infiltrates, microglial nodule reaction, extensive neuronal necrosis, myelin depletion and gliosis. The cerebrum did not show any inflammation and the myocardium showed no myocarditis. The lungs showed extensive oedema with reticulated strands of fibrin within the alveoli. According to the pathology reports, the cause of death in both cases was brain stem encephalitis.
EV 71 was isolated in Vero cells from the medulla, cervical spinal cord and throat swabs in both cases five days post-inoculation.
Prof. S.K. Lam Department of Medical Microbiology University of Malaya Kuala Lumpur Malaysia.
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