620 KH Kim • Enterovirus 71 infection: An experience in Korea, 2009 resonance image. EV71 were detected in the 16 patients presenting neurologic manifestations by realtime PCR. Clinical samples included stools, respiratory secretion, or cerebrospinal f luid obtained from the patients, but viruses were detected from only stools. Subgenotypes of enteroviruses were C1 in the poliomyelitis- like paralytic disease patients, and C4a in eleven patients presenting Guillain-Barré syndrome, meningitis or myoclonus. Among the patients, only one girl presenting poliomyelitis-like paralytic disease still had limping when she was running at three months after discharge, but no death or severe complication with serious disease was observed in any of the other patients1). Diagnosis For virus isolation and detection, proper selection and handling of specimens are most important. Collection of materials from multiple sites is important. Specimen should be collected form nasopharynx, throat, stool, blood, urine, CSF, and other body f luids. Swabs from throat or rectum should be placed in a carrying medium. Fluid specimens should be collected sterile vials. In general, specimen should be refrigerated immediately after collection and during transportation to the laboratory. If an extended period will elapse before examination in the laboratory, shipping and storing it frozen are advisable. During 2009 outbreaks in Korea, examinations for the viruses were carried out at the Division of Enteric and Hepatitis Viruses, Korea Centers of Diseases Control and Prevention. EV71 wa s isolated from specimens by rea l time-PCR . Viral RNA was extracted using ZR Viral RNA Kit (Zymo Research, Orange, CA, USA) according to the manufacturer’s instructions. The whole genomic RNA was reverse transcribed for cDNA synthesis. A mplicons of the V P1 genes were Fig. 2. Origins and numbers of samples of EV71 isolation during 2009 outbreaks in Korea generated by using primers as follows: forward primer, SO224 (5’-GCIATGYTIGGIACICAYRT-3’), and reverse primer, SO222 (5’-CICCIGGIGGIAYRWACAT-3’) (1st-PCR); forward primer, AN89 (5’-CCAGCACTGACAGCAGYNGAR AYNGG-3’), and reverse primer, AN88 (5’-TACTGGACCACCTGGNGG NAYRWACAT-3’) (2nd-PCR). These PCR products were then sequenced using ABI PRISM dye terminator cycle sequencing ready reaction kit (Perkin Elmer, Waltham, Massachusetts, USA), and run on an ABI 3100 sequencer (Applied Biosystems, Foster City, CA, USA). Nucleotide sequences were determined by the DNASTAR1). The virus was detected from rectal swab, stool, throat, tracheal aspirates and CSF specimens with various detectable rates (Fig. 2). Treatment The mainstay of treatment for EV71 disease is supportive management. There is currently no specific antiviral agent to treat or vaccine to prevent EV71 diseases. All patients who demonstrate the neurological symptoms and signs should be hospitalized. If the patient has been diagnosed with uncomplicated brainstem encephalitis, close monitoring of the myoclonic jerks and vital signs is mandatory. Since the target central neurologic system is the brainstem, rather than the cerebrum, increased intracranial pressure is rarely encountered and the administration of osmotic diuretics is usually unnecessary36). Treating severe EV71 brainstem encephalitis patients with intravenous immunoglobulin is associated with significantly decreased mortality by attenuated sympathetic activity and cytokine (IL-6 and IL-8) production. Furthermore, patients presenting with acute flaccid paralysis combined with pleocytosis in the CSF should also receive IVIG infusion. A specific recommendation dose is unknown. Experts recommend that IVIG 1 g/kg should be initiated for the first day, and if ANS dsyregulation does not improve, a second dose should be administered the following day37). The antiviral drug pleconaril offers promise for the treatment of enteroviral infection. It prevents the virus from attachment to cellular receptors and the uncoating and subsequent release of viral RNA into the host cell. Pleconaril is not available in Korea. Infection control and prevention As it has been reported that some serious cases causing death or severe neurologic complications were associated with the EV71 infection in 2009, EV71 infection has become an important issue