Cardosa, Mary Jane

Clear, Daniela

Kneen, Rachel

Krishnan, Shekhar

Mong, How Ooi

Perera, David

Phaik, Hooi Tio

Preston, Teresa

See, Chang Wong

Solomon, Tom

Tedman, Brian

Willison, Hugh J.

Unimas Institutional Repository

550 • CID 2003:36 (1 March) • Ooi et al.M A J O R A R T I C L EAdenovirus Type 21–Associated Acute FlaccidParalysis during an Outbreak of Hand-Foot-and-Mouth Disease in Sarawak, MalaysiaMong How Ooi,1 See Chang Wong,1 Daniela Clear,3 David Perera,2 Shekhar Krishnan,1 Teresa Preston,4Phaik Hooi Tio,2 Hugh J. Willison,6 Brian Tedman,4 Rachel Kneen,3 Mary Jane Cardosa,2 and Tom Solomon3,5,a1Department of Paediatrics, Sibu Hospital, Sibu, and 2Institute of Health and Community Medicine, Universiti Malaysia Sarawak, KotaSamarahan, Sarawak, Malaysia; Departments of 3Neurological Science and 4Neurophysiology, Walton Centre for Neurology and Neurosurgery,and 5Department of Medical Microbiology and Genitourinary Medicine, Duncan Building, University of Liverpool, Liverpool, England;and 6University Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland, United KingdomWe report the virological and clinical features of 8 children who presented with adenovirus-associated acuteflaccid paralysis (AFP) during an epidemic of enterovirus type 71 (EV71)–associated hand-foot-and-mouthdisease (HFMD) in Sarawak, Malaysia, in 1997. Neutralization tests and phylogenetic analysis revealed ade-novirus type 21 (Ad21), although DNA restriction digests suggested that this virus was different from theprototype Ad21. Four children had upper-limb monoparesis, 2 had lower-limb monoparesis (one of whomhad changes in the anterior spinal cord noted on magnetic resonance imaging), and 2 had flaccid paraparesis.At follow-up, 4 children were noted to have made full recoveries and 3 had residual flaccid weakness andwasting. Neurophysiological investigation revealed a mixture of axonal and demyelinating features in motorand sensory nerves, with denervation. These findings suggest that Ad21 might cause AFP by anterior horncell damage or neuropathy of the brachial or lumbosacral plexus. The occurrence of these unusual adenovirusinfections during an outbreak of EV71-associated HFMD suggests that an interaction between the 2 virusesmay have occurred.With the decrease in the number of cases of polio inthe tropics, attention has moved to other causes of acuteflaccid paralysis (AFP). In 1997, there was an unex-pected increase in the number of children with AFPwho presented to Sibu Hospital (Sarawak, Malaysia).Received 6 June 2002; accepted 20 October 2002; electronically published 14February 2003.Financial support: Walton Centre for Neurology and Neurosurgery NeuroscienceFund (to D.C.); National Science fellowship, Malaysia (to D.P.), and Wellcome TrustCareer Development fellowship (to T.S.).a Present affiliation: World Health Organization Center for Tropical Diseases,University of Texas Medical Branch, Galveston, Texas.Reprints or correspondence: Dr. Tom Solomon, Dept. of Neurological Science,University of Liverpool, Walton Centre for Neurology and Neurosurgery, LowerLance, Fazakerley, Liverpool L9 7LJ, United Kingdom (tsolomon@liv.ac.uk).Clinical Infectious Diseases 2003; 36:550–9 2003 by the Infectious Diseases Society of America. All rights reserved.1058-4838/2003/3605-0002$15.00The cases occurred during an outbreak of hand-foot-and mouth disease (HFMD) across Sarawak, and theycoincided with an unexplained cluster of children withacute fatal myocardial dysfunction [1]. Although theoutbreak of HFMD was clearly caused by enterovirustype 71 (EV71), obtaining a consensus on the cause ofthe cases involving paralysis and fatal cardiac cases hasproven to be difficult [2, 3]. The clinical and patho-logical characteristics of the fatal cardiac cases have beendescribed in detail elsewhere [4]. Here, we focus on thecases involving paralysis.Although EV71 is known to cause polio-like flaccidparalysis, virological and epidemiological investigationsconducted during this outbreak of disease showed thatthe virus that was most closely associated with the casesof AFP and myocarditis at Sibu Hospital was a speciesB human adenovirus [1]. As has been described else- at UNIVERSITI MALAYSIA SARAWAK on June 16, 2013http://cid.oxfordjournals.org/Downloaded from 

Adenovirus Type 21–Associated Acute Flaccid Paralysis during an Outbreak of Hand-Footand-Mouth Disease in Sarawak, Malaysia

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Adenovirus Type 21–Associated Acute Flaccid Paralysis during an Outbreak of Hand-Footand-Mouth Disease in Sarawak, Malaysia

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