Approach Considerations

In the evaluation of respiratory disease, obtain nasopharyngeal or oropharyngeal swabs and other respiratory specimens such as nasal wash or aspirates, which are high yield for diagnosis.

Initially, the assay used to diagnose enterovirus D68 was real-time RT-PCR (rRT-PCR) developed by the CDC Picornavirus Laboratory. This technique involves sequencing a region of the virus’s genome, which results in complicated large-scale screening.^[38]However, in July 2015, a new assay was developed by researchers at the Washington University School of Medicine in St Louis. This assay is a rRT-PCR that is more sensitive than commercially available assays for enterovirus and rhinovirus detection. This new assay is also more specific for EV-D68, unlike the commercially available assays, which do not distinguish between the two. This newly developed assay was also able to detect divergent strains of EV-D68.^[39]

Chest radiography should also be performed in patients with respiratory symptoms.

If neurological manifestations of paralytic disease or meningoencephalitis are evident, a lumbar puncture and cerebrospinal fluid (CSF) analysis are warranted.^{[24, 37]}If flaccid paralysis is present, MRI of the spine can provide diagnostic data.^[37]If cranial nerve manifestations are present, MRI of the brain should also be obtained.^[37]

Chest Radiography

Chest radiographs show perihilar infiltrates, often with atelectasis when respiratory disease present.^[3]

MRI

In cases of acute flaccid paralysis and cranial nerve dysfunction in children, MRI of the spine demonstrates nonenhancing lesions of the gray matter spanning multiple levels, and MRI of the brain has shown nonenhancing brainstem lesions most commonly localized to the dorsal pons. MRI with gadolinium can show enhancing of ventral nerve roots of the cauda equina.^[29]

Laboratory Studies

Cerebrospinal fluid typically shows a lymphocytic pleocytosis, normal glucose levels, and normal or mildly elevated protein levels, consistent with aseptic meningitis. RT-PCR of CSF yielded negative findings in one case series.^[29]

Nasopharyngeal specimens testing with rRT-PCR is frequently the diagnostic tool used to identify EV-D68.

Blood cultures are negative for bacteria.

Treatment & Management

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Media Gallery

Electron micrograph of a thin section of enterovirus D68 (EV-D68), showing the numerous, spherical viral particles. Courtesy of the CDC.
Electron micrograph of a thin section of numerous spherical enterovirus D68 (EV-D68) viral particles. Some of the particles appear to be "empty," missing their contents of single-stranded RNA. Courtesy of the CDC.

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Enterovirus D68 Workup

Approach Considerations

Chest Radiography

MRI

Laboratory Studies

References

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