Enterovirus D68-Associated Acute Flaccid Myelitis in Immunocompromised Woman, Italy

Abstract

In Italy in 2016, acute flaccid myelitis developed in a woman who had received a hematopoietic stem cell transplant. Enterovirus D68 viral genome was detected in respiratory and cerebrospinal fluid samples, and the viral protein 1 sequence clustered with lineage B3. Immunocompromised adults may be at risk for enterovirus D68-associated neurologic complications.

Keywords: Enterovirus D68; Italy; VP1 sequencing; acute flaccid myelitis; central nervous system infection; human; immunocompromised patient; molecular epidemiology; viruses.

Figure 1

Magnetic resonance images of the brain and spinal cord of a woman who later died of fatal neurologic disease associated with enterovirus D68 infection. A) Sagittal and axial T2 image of the spinal cord showing cord swelling, particularly at the cervical level (arrows). B) Extensive hyperintensity in the central cord.

Figure 2

Phylogenetic tree of partial viral protein 1 sequences of 279 nt (nt positions 2581–2859, reference sequence GenBank accession no.AY426531.1), sequences from cerebrospinal fluid (accession no. MF061604) and oropharyngeal swab sample (accession no. MF061605) from a woman who died of fatal neurologic disease associated with enterovirus-D68 infection (indicated in red) in the context of 918 enterovirus-D68 global sequences retrieved from the National Center for Biotechnology Information (https://www.ncbi.nlm.nih.gov/). The main figure shows the whole maximum-likelihood tree (1,000 bootstrap replicas), generated by using the HKY+GI (Hasegawa-Kishino-Yano + gamma distribution invariant sites) model; the inset shows an enlargement of subclade B3 containing the sequences from the patient reported here and patients involved in the 2016 epidemic in the Netherlands: the closest sequence is KX685068.1_Netherlands_2016 (98% identity, distance: 180 substitutions/10⁴ positions). Red dots indicate nodes with bootstrap value >70.