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Enterovirus D68

What It Is, Transmission, Signs and Symptoms, Treatment, and More

Author: Emily Miao, PharmD

Editors: Alyssa Haag, Ian Mannarino, MD, MBA, Kelsey LaFayette, DNP

Illustrator: Jessica Reynolds, MS

Modified: 5 Mar 2024


What is enterovirus D68?

Enterovirus D68 (EV-D68) is a type of enterovirus that was first identified in California, United States in the 1960s and has sporadically caused respiratory illness among children with asthma and other underlying respiratory conditions. Additionally, EV-D68 can rarely cause acute flaccid myelitis in young children, an uncommon but serious condition that causes muscle weakness, paralysis, and decreased reflexes. EV-D68 is a member of the Picornaviridae family and Enterovirus genus. Enteroviruses are a broad group of viruses that cause diseases ranging from mild to severe, including respiratory infections and viral meningitis. While prevalence varies per year and by geographic location, outbreaks tend to occur during late summer and fall. Nonetheless, individuals can be infected year-round. In the past few decades, the incidence of EV-D68 has been increasing, with a nationwide respiratory illness outbreak that occurred in the United States between August and November of 2014. Since then, the Centers for Disease Control and Prevention (CDC) have implemented a surveillance program to raise awareness of enterovirus infection with EV-D68.

Upper respiratory infection symptoms.

How is enterovirus D68 transmitted?

EV-D68 spreads from person to person when an individual comes in contact with the virus either directly or indirectly through a contaminated surface. EV-D68 is primarily found in the respiratory tract and secretions (e.g., saliva, nasal mucosa, sputum) of people who are sick. When an infected individual coughs and sneezes, they spread the virus-containing particles into the air. These droplets can land on nearby individuals or remain in the environment, including any surfaces that the infected individual has touched. Therefore, protection from exposure to this virus and infected fomites is dependent on washing hands often with soap and water and by wearing a face mask.

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What signs and symptoms does enterovirus D68 infection cause?

The symptoms of EV-D68 infection range from mild to severe, and are similar to those seen with other respiratory illnesses, including influenza and the common cold. EV-D68 has an incubation period ranging from 3 to 10 days, which is the time between coming in contact with the virus and the first appearance of symptoms. Most individuals experience either no symptoms at all (i.e., asymptomatic) or mild symptoms such as runny nose, sore throat, sneezing, cough, and myalgias. Individuals with underlying pulmonary disease (e.g., chronic obstructive pulmonary disease, or COPD) may experience severe symptoms such as wheezing and difficulty breathing, although these are less common. Notably, children with underlying respiratory conditions such as asthma or concomitant bronchiolitis, may also experience a more severe disease course (e.g., respiratory distress)

Rarely, EV-D68 has been known to cause acute flaccid myelitis (AFM), a serious neurologic condition that affects the nervous system, specifically the gray matter of the spinal cord. AFM mostly affects young children and causes the body’s muscles and reflexes to become weak. Other signs and symptoms of AFM include difficulty swallowing, slurred speech, facial droop, and drooping eyelids. 

How is an enterovirus D68 infection diagnosed and treated?

Diagnosis of EV-D68 infection begins with a thorough review of symptoms and medical history.  A throat or nasal swab can be helpful in determining the etiology of infection (e.g., bacterial or viral). Although further testing is often not needed due to the self-resolving nature of the respiratory infection, testing can confirm the etiology. Testing for enterovirus is often incorporated into multiplex respiratory panels, which also test for various common respiratory pathogens (e.g., coronavirus, enterovirus, influenza). To identify the specific strain, specific laboratory blood testing with molecular sequencing methods is required, such as reverse transcription polymerase chain reaction (RT-PCR). RT-PCR is a sequencing method that detects the genetic material of a pathogen (e.g., RNA from EV-D68) and subsequently produces a genetic code (i.e., DNA) of the detected pathogen.

There is no specific treatment for individuals with EV-D68 infection. Most individuals experience a mild self-limiting disease, therefore management is aimed at supportive measures to improve symptom burden. Supportive measures include adequate rest and hydration with oral fluids, and over-the-counter medications such as acetaminophen or ibuprofen to manage fever and alleviate muscle aches and pains. Saline nasal sprays and humidifiers may help with nasal congestion and salt water rinses can help relieve sore throat. If symptoms worsen with significant respiratory compromise (e.g., shortness of breath, wheezing) or signs of AFM are present, individuals should seek emergency medical attention immediately. Treatment for AFM includes a combination of supportive measures (e.g., hydration with fluids); steroids (e.g., dexamethasone); plasmapheresis (i.e., removal or exchange of components in blood plasma); and intravenous immunoglobulin (IVIG), a pooled antibody used to treat various autoimmune, infectious, and inflammatory conditions. Frequent washing of hands with soap and water can help in preventing transmission to others. 

What are the most important facts to know about enterovirus D68?

Enterovirus D68 (EV-D68) is a type of enterovirus that was first identified in California, United States in the 1960s and can cause respiratory illness most commonly among children with asthma and other underlying respiratory conditions. EV-D68 is primarily found in the respiratory tract and secretions (e.g., saliva, nasal mucosa, sputum) of people who are sick and spreads from person to person through respiratory droplets. Most individuals experience either no symptoms at all (i.e., asymptomatic) or mild symptoms such as runny nose, sore throat, sneezing, cough, and myalgias. Individuals with underlying respiratory condition may experience severe symptoms such as wheezing and difficulty breathing, although these are less common. Management is aimed at supportive measures including adequate rest and hydration with oral fluids, over-the-counter medications such as acetaminophen or ibuprofen, and saline nasal sprays for congestion. To prevent EV-D68 infection, avoid touching your eyes, nose, and mouth with unwashed hands and frequently wash your hands with soap and water.

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Related links

Respiratory system anatomy and physiology
Viral exanthems of childhood: Pathology review

Resources for research and reference

Abedi GR, Watson JT, Nix WA, Oberste MS, Gerber SI. Enterovirus and Parechovirus surveillance - United States, 2014-2016. MMWR Morb Mortal Wkly Rep. 2018;67(18):515-518. Published 2018 May 11. doi:10.15585/mmwr.mm6718a2

Centers for Disease Control and Prevention. Enterovirus D68. Published July 11, 2023. Accessed November 29, 2023. https://www.cdc.gov/non-polio-enterovirus/hcp/ev-d68-hcp.html 

Centers for Disease and Control and Prevention. About Enterovirus D68. Published September 9, 2022. Accessed November 29, 2023. https://www.cdc.gov/non-polio-enterovirus/about/ev-d68.html 

Jubelt B, Lipton HL. Enterovirus/picornavirus infections. Handb Clin Neurol. 2014;123:379-416. doi:10.1016/B978-0-444-53488-0.00018-3

Messacar K, Abzug MJ, Dominguez SR. The Emergence of Enterovirus-D68. Microbiol Spectr. 2016;4(3):10.1128/microbiolspec.EI10-0018-2016. doi:10.1128/microbiolspec.EI10-0018-2016