Enteroviral Rhombencephalitis with Abducens Nerve Palsy and Cardio-Pulmonary Failure in a 2-Year-Old Boy

Abstract

Enterovirus infection is endemic in many areas, especially in Southeast Asia. Enterovirus infection with severe complications (EVSC) is life-threatening, and timely diagnosis and management are crucial for successful management. Here, we report on a 2-year-old boy with hand, foot, and mouth disease. Myoclonic jerks developed and left abducens nerve palsy followed. Brain magnetic resonance imaging (MRI) showed rhombencephalitis. Pulmonary edema and cardiopulmonary failure developed, and intravenous immunoglobulin and extracorporeal membrane oxygenation were administered. He had a tracheostomy with home ventilator use after 64 days of hospitalization. At a 5-year follow-up, his neurodevelopment was normal with complete recovery from the abducens nerve palsy. The progress of EVSC may be rapid and fulminant, and timely diagnosis is critical for patient prognosis and outcomes. The presence of abducens nerve palsy is an indicator of enteroviral rhombencephalitis, and immediate and appropriate management is suggested.

Keywords: brainstem encephalitis; enterovirus; enterovirus infection with severe complications; extracorporeal membrane oxygenation; intravenous immunoglobulin; rhombencephalitis.

Figure 1

Eye movement was restricted in the left eye only on lateral gaze, and a left abducens nerve palsy was diagnosed.

Figure 2

Brain magnetic resonance imaging showed symmetric lesions involving the dorsal pons and medulla oblongata, revealing brainstem encephalitis. These lesions (arrow) were hypointense in the T1-weighted FLAIR sequence panel (A) and hyperintense in the T2-weighted FLAIR images panel (B).