Enteroviral infection in Child
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
- 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.)
- Myocarditis / pericarditis – Upper respiratory symptoms typically precede onset of fatigue, chest pain, and shortness of breath.
- Central nervous system (CNS) disease – See below.
- Viral meningitis – Fever, irritability, headache, stiff neck, photophobia, nausea, vomiting
- Encephalitis / meningoencephalitis – Acute onset of altered mental status, abnormal neurologic examination, 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. Acute flaccid paralysis temporally associated with the EV-D68 outbreak is referred to as acute flaccid myelitis. Per the Centers for Disease Control and Prevention (CDC), on September 9, 2022, the CDC Health Alert Network urged health care providers to consider EV-D68 as a possible cause of acute, severe respiratory illness (with or without fever) in children and the potential for an increase in acute flaccid myelitis cases in the upcoming weeks.
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
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.
- Community acquired bacterial pneumonia (Streptococcus pneumoniae, Haemophilus influenzae) – Focal lung and radiographic findings.
- Atypical pneumonia (Mycoplasma pneumoniae, Chlamydia pneumoniae) – Typically mild, insidious onset; can cause diffuse rales and wheezing.
- Asthma / reactive airways disease – Enteroviruses may trigger asthma / reactive airways disease.
- Other respiratory viruses (respiratory syncytial virus, influenza, rhinovirus, coronavirus [eg, SARS, MERS-CoV], adenovirus, human metapneumovirus) – Can present with similar clinical findings.
- 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.
- Bacterial meningitis (S pneumoniae, H influenzae, Neisseria meningitidis) – Ill-appearing children with high fever and meningeal signs. Typically high cerebrospinal fluid (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.