You have been logged out of VisualDx or your session has expired.

Please reload this page and sign into VisualDx to continue.

  VisualDx Mobile   Select Language

Get VisualDx Mobile

There are VisualDx mobile apps available for iOS and Android devices.

You will need a VisualDx account to use the mobile apps.

Already have an account? Sign In or
sign up for a free trial.

Users with VisualDx accounts earn CME credits for using VisualDx.

Already have an account? Sign In or
sign up for a free trial.

Create a Personal Account

E-mail (username)
Verify Password
First Name
Last Name

Personal Account Created

Mobile Access

You can now download VisualDx for your iOS and Android devices. Launch the VisualDx app from your device and sign in using your VisualDx personal account username and password.

CME Certification

Sign in with your personal account to earn and claim CME credits through VisualDx. Credits can be earned by building a differential or looking up a diagnosis.

Version: 7.13.1441   (build df7aed4)
Select Language

Select Region

Send us your feedback

This field is required

Oops! There was an issue during submission. Please try again. If the problem persists, email with your feedback.

Thank You!

We appreciate your feedback and you will be hearing from us soon.


Share This Page

Thank You!

We have sent an e-mail with a link to the current page.


E-mail This Patient Information Sheet

Thank You!

We have sent an e-mail with this patient information.


Image Contributors


  • Christine Ahn MD
    Carl Allen DDS, MSD
    Brandon Ayres MD
    Howard P. Baden MD
    Robert Baran MD
    Keira Barr MD
    Gregory J. Basura MD, Ph.D
    Donald Belsito MD
    Jeffrey D. Bernhard MD
    Jesse Berry MD
    Victor Blanco MD
    Benjamin R. Bohaty MD
    William Bonnez MD
    Sarah Brenner MD
    Robert A. Briggaman MD
    Robert Brodell MD
    Roman Bronfenbrener MD
    Walter Brooks MD
    William Buckley MD
    Philip Bulterys MD, PhD (candidate)
    Susan Burgin MD
    Sonya Burton MD
    Sean P. Bush MD, FACEP
    Jeffrey Callen MD
    Scott Camazine MD
    Michael Cardwell
    Shelley D. Cathcart MD
    Robert Chalmers MD, MRCP, FRCP
    Chia-Yu Chu MD, PhD
    Flavio Ciferri MD
    Maria Rosa Cordisco MD
    Noah Craft MD, PhD
    John T. Crissey MD
    Harold E. Cross MD, PhD
    Charles E. Crutchfield III MD
    Adriana Cruz MD
    Donna Culton MD, PhD
    Bart J. Currie MBBS, FRACP, DTM&H
    Chicky Dadlani MD
    Alexander Dane DO
    C. Ralph Daniel III MD
    Thomas Darling MD, PhD
    William Delaney MD
    Damian P. DiCostanzo MD
    Ncoza Dlova MD
    James Earls MD
    Libby Edwards MD
    Melissa K. Egge MD
    Charles N. Ellis MD
    Rachel Ellis MD
    David Elpern MD
    Nancy Esterly MD
    Stephen Estes MD
    E. Dale Everett MD
    Janet Fairley MD
    David Feingold MD
    Jennifer J. Findeis-Hosey MD
    Benjamin Fisher MD
    Henry Foong MBBS, FRCP
    David Foster MD, MPH
    Brian D. Foy PhD
    Michael Franzblau MD
    Vincent Fulginiti MD
    Sunir J. Garg MD, FACS
    Kevin J. Geary MD
    Lowell Goldsmith MD, MPH
    Sethuraman Gomathy MD
    Bernardo Gontijo MD, PhD
    Kenneth Greer MD
    Kenneth G. Gross MD
    Alan Gruber MD
    Nathan D. Gundacker MD
    Akshya Gupta MD
    Vidal Haddad MSC, PhD, MD
    Edward Halperin MD, MA
    Ronald Hansen MD
    John Harvey
    Rizwan Hassan MD
    Michael Hawke MD
    Jason E. Hawkes MD
    Peter W. Heald MD
    David G. Hicks MD
    Sarah Hocker DO
    Ryan J. Hoefen MD, PhD
    Li-Yang Hsu MD
    William Huang MD
    Sanjana Iyengar MD
    Alvin H. Jacobs MD
    Saagar Jadeja MD
    Shahbaz A. Janjua MD
    Joshua J. Jarvis MD
    Kit Johnson
    Zachary John Jones MD
    Robert Kalb MD
    A. Paul Kelly MD
    Henry Kempe MD
    Loren Ketai MD
    Sidney Klaus MD
    Ashwin Kosambia MD
    Jessica A. Kozel MD
    Carl Krucke
    Mario E. Lacouture MD
    Joseph Lam MD
    Alfred T. Lane MD
    Edith Lederman MD
    Nahyoung Grace Lee MD
    Pedro Legua MD, PhD
    Robert Levin MD
    Bethany Lewis MD
    Sue Lewis-Jones FRCP, FRCPCH
    Taisheng Li MD
    Christine Liang MD
    Shari Lipner MD, PhD
    Adam Lipworth MD
    Jason Maguire MD
    Mark Malek MD, MPH
    Jere Mammino DO
    Ricardo Mandojana MD
    Lynne Margesson MD
    Thomas J. Marrie MD
    Maydel Martinez MD
    Ralph Massey MD
    Patrick McCleskey MD
    Karen McKoy MD
    Thomas McMeekin MD
    Josette McMichael MD
    Somchai Meesiri MD
    Joseph F. Merola MD
    Mary Gail Mercurio MD
    Anis Miladi MD
    Larry E. Millikan MD
    Dan Milner Jr. MD
    Zaw Min MD
    Stephanie Montero
    Alastair Moore MD
    Keith Morley MD
    Dean Morrell MD
    Samuel Moschella MD
    Rehan Naseemuddin MD
    Taimor Nawaz MD
    Vic Newcomer MD
    John Nguyen MD
    Matilda Nicholas MD
    Thomas P. Nigra MD
    Steven Oberlender MD, PhD
    Maria Teresa Ochoa MD
    Art Papier MD
    Lawrence Parish MD
    Tanner Parrent MD
    Mukesh Patel MD
    Lauren Patty-Daskivich MD
    David Peng MD, MPH
    Robert Penne MD
    Nitipong Permpalung MD
    Miriam Pomeranz MD
    Doug Powell MD
    Harold S. Rabinovitz MD
    Christopher J. Rapuano MD
    Sireesha Reddy MD
    Angela Restrepo MD, PhD
    Bertrand Richert MD, PhD
    J. Martin Rodriguez, MD, FACP
    Theodore Rosen MD
    Misha Rosenbach MD
    Scott Schiffman MD
    Robert H. Schosser MD
    Glynis A. Scott MD
    Carlos Seas MD, MSc
    Deniz Seçkin MD
    Daniel Sexton MD
    Paul K. Shitabata MD
    Tor Shwayder MD, FAAP, FAAD
    Elaine Siegfried MD
    Gene Sienkiewicz MD
    Christye Sisson
    Philip I. Song MD
    Mary J. Spencer MD, FAAP
    Lawrence B. Stack MD
    Sarah Stein MD
    William Van Stoecker MD
    Frances J. Storrs MD
    Erik J. Stratman MD
    Lindsay C. Strowd MD
    Erika Summers MD
    Belinda Tan MD, PhD
    Robert Tomsick MD
    Hensin Tsao MD, PhD
    Richard P. Usatine MD
    Jenny Valverde MD
    Vishalakshi Viswanath MD
    Susan Voci MD
    Lisa Wallin ANP, FCCWS
    Douglas Walsh MD
    Ryan R. Walsh MD
    George Watt MD
    Clayton E. Wheeler MD
    Sally-Ann Whelan MS, NP, CWOCN
    Jan Willems MD, PhD
    James Henry Willig MD, MPH
    Karen Wiss MD
    Vivian Wong MD, PhD
    Sook-Bin Woo MS, DMD, MMSc
    Jamie Woodcock MD
    Stephen J. Xenias MD
    Nathaniel Yohannes
    Lisa Zaba MD
    Vijay Zawar MD
    Bonnnie Zhang MD
    Carolyn Ziemer MD
    Jeffrey P. Zwerner MD, PhD


  • Am. Journal of Trop. Med & Hygiene
  • Armed Forces Pest Management Board
  • Blackwell Publishing
  • Bugwood Network
  • Centers For Disease Control and Prevention
  • Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
  • Dermatology Online Journal
  • East Carolina University (ECU), Division of Dermatology
  • International Atomic Energy Agency
  • Massachusetts Medical Society
  • Oxford University Press
  • Radiological Society of North America
  • Washington Hospital Center
  • Wikipedia
  • World Health Organization
ContentsSynopsisCodesLook ForDiagnostic PearlsDifferential Diagnosis & PitfallsBest TestsManagement PearlsTherapyReferencesView all Images (12)
Enteroviral infection in Child
Other Resources UpToDate PubMed

Enteroviral infection in Child

Print Images (12)
Contributors: Kevin Messacar MD, Mark J. Abzug MD, Ricardo M. La Hoz MD
Other Resources UpToDate PubMed


Enteroviruses include the polioviruses (not covered in this section), coxsackieviruses, echoviruses, and the numbered enteroviruses (eg, EV-A71, EV-D68).

Enterovirus infections are common in children and can clinically manifest in a variety of ways, including:
  • Nonspecific febrile illness – Fever and irritability, particularly in infants.
  • Exanthems and enanthems – Herpangina, hand-foot-mouth disease, and nonspecific exanthems. (See also Herpangina, Hand-foot-and-mouth disease, and Viral exanthem)
  • Neonatal viral sepsis (See neonate/infant summary of Enteroviral infection.)
  • Respiratory disease – Upper respiratory tract symptoms, eg, sore throat and coryza, are common with enterovirus infections. Lower respiratory tract involvement may include pneumonia and bronchiolitis. Pleurodynia is associated with paroxysmal thoracic pain. EV-D68 has been associated with lower respiratory tract disease, both in children with and without asthma.
  • Acute hemorrhagic conjunctivitis – Epidemic; associated with severe eye pain, photophobia, conjunctival erythema, and congestion. (See also Hemorrhagic Viral Conjunctivitis in VisualDx.)
  • Myocarditis / pericarditis – Upper respiratory symptoms typically precede onset of fatigue, chest pain, and shortness of breath.
  • Central nervous system (CNS) disease – See below.
CNS disease:
  • Viral meningitis – Fever, irritability, headache, stiff neck, photophobia, nausea, vomiting
  • Encephalitis / meningoencephalitis – Acute onset of altered mental status, abnormal neurologic exam, and/or seizures. Brainstem encephalitis (EV-A71) can lead to noncardiogenic pulmonary edema and nonmyocarditic cardiopulmonary collapse.
  • Polio-like acute flaccid paralysis – Prodromal febrile illness followed by acute, typically asymmetric, flaccid weakness of the limbs with decreased reflexes and intact sensation; cranial nerve dysfunction may also be present. Several nonpolio enteroviruses are associated with acute flaccid paralysis in children similar to that caused by polioviruses. Most notably, clusters of acute flaccid paralysis in children have been associated with EV-A71 outbreaks, some of which have been widespread in parts of Asia. Geographic and temporal association of acute flaccid paralysis and cranial nerve dysfunction in children during outbreaks of EV-D68 respiratory disease in 2014 in the United States was noted. As virus has not been identified in spinal fluid in these cases, definitive evidence of causation is lacking. Per the CDC, acute flaccid paralysis temporally associated with the 2014 EV-D68 outbreak is being referred to as acute flaccid myelitis.
Enterovirus infections can occur throughout the year but most commonly cause outbreaks of disease in the late summer and early fall in temperate regions.

Most enterovirus infections are self-limited and not immediately life-threatening. However, some presentations can represent life-threatening emergencies, including brainstem encephalitis, myocarditis, severe respiratory distress, and neonatal enterovirus sepsis. Neonates, children with immunoglobulin deficiencies, and transplant recipients are predisposed to more severe and persistent disease. Long-term morbidity may occur, including chronic dilated cardiomyopathy, persistent neurologic deficits, and polio-like acute flaccid paralytic disease.


A08.39 – Other viral enteritis
B30.3 – Acute epidemic hemorrhagic conjunctivitis (enteroviral)

53648006 – Enteroviral infection

Look For

Subscription Required

Diagnostic Pearls

Subscription Required

Differential Diagnosis & Pitfalls

The differential diagnosis of enteroviral infections depends on the clinical syndrome.

Nonspecific febrile illness:
  • Serious bacterial infection (urinary tract infection, bacteremia, meningitis) – Consider in young infants, ill-appearing children, or patients with prolonged fever without a source.
  • Other viral syndromes (influenza, HHV-6 [eg, roseola], parechoviruses) – May be difficult to clinically differentiate.
Respiratory disease:
Myocarditis / pericarditis:
  • Noninfectious heart failure – Lacks prodromal illness, associated viral symptoms, multiorgan system involvement.
  • Bacterial pericarditis (Staphylococcus aureus, H. influenzae, M. pneumoniae) – Typically high fever, purulent pericardial effusion, elevated inflammatory markers. Positive blood or pericardial bacterial cultures.
  • Other viruses (adenovirus, influenza, etc) – Can present similarly and be difficult to differentiate. Viral PCR of nasopharynx, bronchoalveolar lavage, blood, pericardial fluid, or myocardial biopsy can assist in identification.
Central nervous system disease – Viral meningitis, encephalitis, and polio-like acute flaccid paralysis:
  • Bacterial meningitis (S. pneumoniae, H. influenzae, Neisseria meningitidis) – Ill-appearing children with high fever and meningeal signs. Typically high CSF white blood count (>500/mm3), low CSF glucose, high CSF protein. Positive CSF gram stain and culture.
  • Viral meningitis / encephalitis / paralytic disease (parechoviruses, HSV, West Nile virus, and other arboviruses, influenza, adenovirus, Epstein-Barr virus) – Can present similarly and be difficult to differentiate clinically. MRI, lumbar puncture, and PCR and/or serologic testing of CSF, serum, and nonsterile sites can be useful to identify etiologic agent.

Best Tests

Subscription Required

Management Pearls

Subscription Required


Subscription Required


Subscription Required

Last Updated: 11/02/2017
Copyright © 2018 VisualDx®. All rights reserved.
Enteroviral infection in Child
Print 12 Images
View all Images (12)
(with subscription)
Enteroviral infection (Enteroviral Manifestations) : Febrile
Clinical image of Enteroviral infection
Copyright © 2018 VisualDx®. All rights reserved.