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COCA Clinical Reminder: August 27, 2015

Notice to Clinicians: Continued Vigilance Urged for Cases of Acute Flaccid Myelitis


The Centers for Disease Control and Prevention (CDC) is continuing to receive and investigate sporadic reports of acute flaccid myelitis (AFM). To date, CDC has verified reports of 120 children in 34 states who developed AFM. Almost all of the children were hospitalized and most presented with acute onset of areflexic limb weakness, usually following a respiratory or febrile illness. All were characterized by distinctive abnormalities on spinal MRI, where pathologic changes were largely restricted to the central gray matter of the spinal cord and most had cerebrospinal fluid (CSF) with pleocytosis (CSF white blood cell count >5 cells/mm3). Despite extensive testing of patients’ CSF, no pathogen was consistently detected.

CDC is re-emphasizing the importance of continued vigilance by clinicians for cases of AFM among all age groups

As we enter enterovirus season, it is unclear if an increase of AFM could occur again this year. Therefore, continued vigilance and testing of specimens is needed to help clarify a cause and determine the frequency of AFM. Clinicians are urged to report cases of AFM, irrespective of enterovirus status. Reporting of cases will help states and CDC monitor potential increases in this illness and better understand potential causes, risk factors, and preventive measures or therapies.

  • As of June 2015, the Council of State and Territorial Epidemiologists (CSTE) adopted a standardized case definition for AFM, which includes cases of all ages to more accurately determine the overall occurrence of AFM (
  • CDC advises clinicians to report cases of AFM classified as confirmed or probable, irrespective of laboratory results, to the local and/or state health department using the patient summary form ( Forms can be submitted to CDC by email at or via secure fax at 404-471-8442.
  • CDC advises clinicians to collect specimens from patients suspected of having AFM as early as possible in the course of illness (preferably on the day of onset of limb weakness) including CSF, whole blood, serum, stool, a nasopharyngeal aspirate, nasopharyngeal wash, or nasopharyngeal swab [with lower respiratory specimen if indicated], and an oropharyngeal swab. Early specimen collection has the best chance to yield a diagnosis.  Additional instructions regarding specimen collection and shipping can be found at:
    • Clinicians treating patients meeting the AFM case definition should consult with their local and state health department for laboratory testing of CSF, blood, serum, respiratory, and stool specimens for enteroviruses, West Nile virus, and other known infectious etiologies.
    • Health departments may contact CDC for further laboratory and epidemiologic support by phone through the CDC Emergency Operations Center (770-488-7100), or by email at Confirmation of EV-D68 currently requires typing by molecular sequencing.

Recommendations for clinical management and follow-up of patients

Information to help clinicians and public health officials manage care of persons with AFM that meet CDC’s case definition can be found at:

For more information:

Please visit the CDC AFM investigation website ( for updates to the investigation.

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