Enteroviral disease is a common, under-recognized childhood illness.

Epidemiology

• Prevalence - Non-polio enteroviruses cause about 10-15 million symptomatic cases annually in the U.S.
• Age - all ages; severity varies inversely with age
• Occurrence
  • Infections occur throughout the year, but peak in July-October
• Transmission - fecal oral

Organism

• Enteroviruses (EV) are single-stranded RNA viruses in the Picornaviridae family
• >70 recognized enteroviral serotypes
• Wild type poliovirus 1-3 no longer in Western hemisphere due to effective vaccine strategies
• Non-polio enteroviruses include:
  • Coxsackieviruses A 1-22 and 24
  • Coxsackieviruses B 1-6
  • Echoviruses 1-9, 11-27 and 29-31
  • Enteroviruses 68-71

Clinical Presentation

• Nonspecific febrile illness with or without rash
• Acute hemorrhagic conjunctivitis (coxsackie A24 & echovirus 70)
• Hand-foot-mouth disease (echovirus 71)
• Sepsis syndrome in neonates
• Myocarditis (coxsackie B3)
• Hepatitis
• Central nervous system (CNS) infections
  • Aseptic meningitis (meningeal inflammation in absence of bacterial pathogen)
    • Enteroviruses are the most common cause
    • Account for 80-92% of all cases
    • Type of enterovirus varies
    • Clinical manifestations depend upon host
  • Enteroviral encephalitis is less common, but more severe, than aseptic meningitis
    • Global neurologic depression
    • Evidence of focal encephalitis, similar to herpes simplex encephalitis (enterovirus found on brain biopsy)
    • Immunocompromised adults and children with agammaglobulinemia are susceptible to chronic meningitis or meningoencephalitis
• In the neonate, enterovirus may cause severe morbidity and mortality
  • Related to sepsis, meningoencephalitis, myocarditis or hepatitis
  • Complications associated with poor outcome generally occur 1-2 days after birth
    • Suggests prenatal origin of infection
  • Sudden onset of fever, irritability and poor feeding characterize infection
  • One-fourth of children have diarrhea, vomiting and rash (macular or maculopapular)
  • Meningeal involvement in febrile disease 70% of time
• Meningitis beyond neonatal period characterized by sudden onset of fever (38°-40°C)
  • Meningeal irritation (>6 weeks) occurs in >50% of patients
  • Headache and photophobia are almost universally reported
  • Neurologic abnormalities rare
  • Both short and long term outcomes generally good for immunocompetent hosts

Treatment

• Supportive

Diagnosis

• For mild to moderate disease (e.g., upper respiratory symptoms), diagnostic testing usually not indicated
• For disseminated or organ-specific syndromes, laboratory testing is definitely indicated.
  • Culture - throat, stool, blood, CSF
  • Nucleic acid amplification testing (CSF, myocardium)
  • Serologic antibody titers