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Enteroviral infection in Adult
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Enteroviral infection in Adult

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Contributors: Kevin Messacar MD, Mark J. Abzug MD, Ricardo M. La Hoz MD
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Synopsis

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.

Codes

ICD10CM:
A08.39 – Other viral enteritis
B30.3 – Acute epidemic hemorrhagic conjunctivitis (enteroviral)

SNOMEDCT:
53648006 – Enteroviral infection

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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.

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References

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Last Updated: 11/02/2017
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Enteroviral infection in Adult
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