Coxsackievirus

Snapshot

• A 16-year-old boy presents to the emergency room for chest pain and shortness of breath. He has no history of congenital heart disease. He recently attended a month-long camp with other teenagers, several of whom had viral illnesses. On physical exam, he has marked tachycardia and a low-grade fever. An echo shows left ventricular dysfunction and a cardiac magnetic resonance imaging reveals myocarditis. Serology confirms that the etiology is viral.

Introduction

• Classification
  • coxsackievirus 
    • an enterovirus that belongs to the picornavirus family
    • non-enveloped, icosahedral capsid, linear, single-stranded, positive-sense RNA virus
    • transmission via oral secretions or feces
    • coxsackievirus type A
      • hand, foot, and mouth disease
      • herpangina
    • coxsackievirus type B
      • most commonly causes nonspecific prodrome
      • myocarditis
      • pericarditis
• Epidemiology
  • incidence
    • common in children
  • demographics
    • more common in children
  • risk factors
    • exposure to others with the virus
    • daycare centers
    • poor hygiene
    • finger sucking
• Pathogenesis
  • once infected, the virus will travel to the lymph nodes and incubate, causing a prodrome
• Prognosis
• typically spontaneously resolves

Presentation

• Hand, foot, and mouth disease
  • vesicles on the palms and soles  
  • may also be erythematous papules
  • vesicles and ulcers in oral mucosa
• Herpangina 
  • ulcers and vesicles in oral mucosa
• Myocarditis 
  • heart failure
  • chest pain
  • arrhythmias
  • tachycardia out of proportion to fever
• Pericarditis
  • sharp pleuritic chest pain
    • relieved by sitting up and forward
• friction rub on exam

Studies

• Labs
  • coxsackievirus-specific immunoglobulin A
  • viral culture
• Making the diagnosis
• based on clinical presentation but may be confirmed with laboratory studies

Differential

• Rickettsia rickettsii infection
  • distinguishing factor
    • also presents with rash on palms and soles but is often not macular and not vesicular in nature
• Chickenpox
  • distinguishing factor
• itchy vesicular rash that typically does not occur on the palms, soles, and oral mucosa

Treatment

• Management approach
  • mainstay of treatment is supportive care and treating any organ failure (such as heart failure in myocarditis)
• Conservative
  • supportive care
    • indication
      • all patients
    • modalities
      • antipyretics
      • analgesics
• hydration

Complications

• Aseptic meningitis
• Guillain-Barre syndrome