Enterovirus D-68

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Aug 2025

Last updated: 17 Nov 2022

Enterovirus D-68 (EV-D68) is an important cause of viral lower respiratory tract illness in children. In 2014, the US experienced an outbreak of EV-D68, with numerous children requiring hospital admission due to severe lower respiratory illness and asthma.

Most people infected have mild symptoms such as runny nose, cough, sneezing, or muscle aches; some patients have fever. Often patients with more severe disease have a history of asthma or chronic lung disease.

A possible association exists between EV-D68 infection and polio-like acute flaccid myelitis.

Diagnosis is clinical. Most clinical tests for rhinovirus do not distinguish EV-D68 in the absence of specific testing.

Specific testing for EV-D68 should be considered in children with severe unexplained respiratory illness, even in the absence of fever. Although not routinely available, specific testing can be obtained on a case-by-case basis through state or local health departments, or the Centers for Disease Control and Prevention.

In patients with mild upper respiratory symptoms, the illness is typically self-limited and no specific therapy is indicated.

Patients with asthma exacerbation or severe unexplained respiratory illness should receive supportive care. Management should occur in a setting that can provide access to appropriate paediatric subspecialty and critical care support. Currently there is no specific antiviral therapy available for the treatment of any enterovirus.

Preventive measures to avoid transmission include avoiding close contact with sick persons, washing hands with soap and water, covering coughs and sneezes, staying home when sick, and cleaning and disinfecting contaminated surfaces. In the healthcare setting, healthcare providers should use standard, contact, and droplet precautions.

Definition

Enterovirus D-68 (EV-D68) is a member of the Picornaviridae family. It has emerged as an important cause of acute respiratory illness, especially in children.[1][2][3] In 2014, the US experienced an outbreak, with numerous children requiring hospital admission due to severe lower respiratory illness and asthma. Emerging data also support a role for EV-D68 in polio-like acute flaccid myelitis.[4][5][6][7] EV-D68 is closely related to rhinoviruses. Most clinical tests for rhinovirus do not distinguish EV-D68 in the absence of strain-specific typing.[8][Figure caption and citation for the preceding image starts]: MRI of the spine showing a T2/STIR hyperintensity restricted to the ventral grey matter of the cervical and thoracic spinal cord in a child with acute flaccid myelitis.From the collection of Neil Friedman, MBChB, Center for Pediatric Neurology, Cleveland Clinic, Cleveland, Ohio [Citation ends]. com.bmj.content.model.Caption@65632c6b

History and exam

Key diagnostic factors

presence of risk factors
wheezing
shortness of breath
acute flaccid limb weakness

Full details

Other diagnostic factors

rhinorrhoea
cough
sneezing
muscle aches
fever

Full details

Risk factors

<18 years of age
history of asthma, wheezing
history of chronic lung disease
late summer or autumn

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

respiratory viral testing
real-time reverse transcription (rRT) PCR assay or molecular sequencing
pulse oximetry
contrast MRI of the spine and brain
lumbar puncture
electromyography
testing for poliovirus

Full details

Treatment algorithm

ONGOING

with mild upper respiratory symptoms

with asthma exacerbation or severe unexplained lower respiratory illness

with acute flaccid myelitis

Contributors

Authors

Charles B. Foster, MD

Professor of Pediatrics

Medical Director of Pediatric Infection Prevention

Center for Pediatric Infectious Diseases

Cleveland Clinic Children’s

Cleveland Clinic

Cleveland

Disclosures

CF declares that he has no competing interests.

Giovanni Piedimonte, MD, FAAP, FCCP

Vice-President for Research and Institutional Official

Office of Research; Departments of Pediatrics, Biochemistry & Molecular Biology

Tulane University

New Orleans

Disclosures

GP declares that he has no competing interests.

Neil R. Friedman, MD

Interim Director, Barrow Neurological Institute at Phoenix Children’s

Director of Clinical Transformation

Barrow Neurological Institute at Phoenix Children’s

Phoenix

Disclosures

NRF declares that he has no competing interests.

Peer reviewers

Feras Khan, MD

Clinical Assistant Professor

Emergency Medicine Physician

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore

Disclosures

FK declares that he has no competing interests.

Samuel R. Dominguez, MD, PhD

Associate Professor

Pediatric Infectious Disease

Children’s Hospital Colorado and University of Colorado School of Medicine

Aurora

Disclosures

SRD declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Oermann CM, Schuster JE, Conners GP, et al. Enterovirus D68: a focused review and clinical highlights from the 2014 United States outbreak. Ann Am Thorac Soc. 2015 May;12(5):775-81. Abstract

Midgley CM, Jackson MA, Selvarangan R, et al. Severe respiratory illness associated with enterovirus d68 - missouri and illinois, 2014. MMWR Morb Mortal Wkly Rep. 2014 Sep 12;63(36):798-9.Full text Abstract

Pastula DM, Aliabadi N, Haynes AK, et al. Acute neurologic illness of unknown etiology in children: Colorado, August - September 2014. MMWR Morb Mortal Wkly Rep. 2014 Oct 10;63(40):901-2.Full text Abstract

Greninger AL, Naccache SN, Messacar K, et al. A novel outbreak enterovirus D68 strain associated with acute flaccid myelitis cases in the USA (2012-14): a retrospective cohort study. Lancet Infect Dis. 2015 Jun;15(6):671-82. Abstract

Oberste MS, Maher K, Schnurr D, et al. Enterovirus 68 is associated with respiratory illness and shares biological features with both the enteroviruses and the rhinoviruses. J Gen Virol. 2004 Sep;85(Pt 9):2577-84. Abstract

Centers for Disease Control and Prevention. Enterovirus D68 for health care professionals. Nov 2018 [internet publication].Full text

Centers for Disease Control and Prevention. Acute flaccid myelitis (AFM): initial evaluation and diagnostic studies. Jul 2022 [internet publication].Full text

Centers for Disease Control and Prevention. Acute flaccid myelitis (AFM): case definitions for AFM. Jul 2022 [internet publication].Full text

Centers for Disease Control and Prevention. Acute flaccid myelitis (AFM): clinical guidance for the acute medical treatment of AFM. Jul 2022 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Rhinovirus infection
- Seasonal influenza infection
- Respiratory syncytial virus infection
More Differentials
Guidelines
- Acute flaccid myelitis (AFM): clinical guidance for the acute medical treatment of AFM
- Acute flaccid myelitis (AFM): initial evaluation and diagnostic studies
More Guidelines
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Enterovirus D-68

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

with mild upper respiratory symptoms

with asthma exacerbation or severe unexplained lower respiratory illness

with acute flaccid myelitis

Contributors

Authors

Charles B. Foster, MD

Disclosures

Giovanni Piedimonte, MD, FAAP, FCCP

Disclosures

Neil R. Friedman, MD

Disclosures

Peer reviewers

Feras Khan, MD

Disclosures

Samuel R. Dominguez, MD, PhD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice