Disease: Coxsackie Virus

    Coxsackie virus facts

    • Coxsackie viruses are RNA viruses that may cause hand, foot, and mouth disease (HFMD).
    • HFMD usually occurs in children but can occur in adults.
    • The majority of HFMD infections are self-limited, so no treatment is required.
    • HFMD, caused by coxsackie viruses, usually causes fever, malaise, rash, and small blisters that ulcerate. The most frequent locations for the blisters/ulcers are on the palms of the hand, soles of the feet, and in the mouth.
    • HFMD usually resolves in about 10 days with no scarring, but the person may shed coxsackie virus for several weeks.
    • Although lab tests for coxsackie viruses can be done, the vast majority of infections are diagnosed by clinical features (HFMD blisters/ulcers), but this may change with the onset of new outbreaks and causes of severe HFMD.
    • There is no specific treatment or vaccine available for coxsackie virus infections.
    • Prevention is difficult; avoid direct contact with anyone with HFMD, and their stool, saliva, and blister fluid. Hand washing and cleaning of items handled by HFMD patients are the best additional methods for prevention.

    What is coxsackie virus?

    Coxsackie virus is a member of the Picornaviridae family of viruses in the genus termed Enterovirus. Coxsackie viruses are subtype members of Enterovirus that have a single strand of ribonucleic acid (RNA) for its genetic material. The enteroviruses are also referred to as picornaviruses (pico means "small," so "small RNA viruses"). Coxsackie virus was first isolated from human feces in the town of Coxsackie, N.Y., in 1948 by G. Dalldorf. Coxsackie virus is also written as coxsackievirus in some publications.

    What are the types of coxsackie viruses, and what can they cause?

    Coxsackie viruses are separable into two groups, A (CVA) and B (CVB), which are based on their effects on newborn mice (coxsackie A results in muscle injury, paralysis, and death; coxsackie B results in organ damage but less severe outcomes.) There are over 24 different serotypes of the virus (having distinct proteins on the viral surface). Coxsackie viruses infect host cells and cause host cells to break open (lyse).

    Picture of the coxsackie virus; SOURCE: CDC

    Type A viruses cause herpangina (painful blisters in the mouth, throat, hands, feet, or in all these areas). Hand, foot, and mouth disease (HFMD) is the common name of this viral infection. Coxsackie A 16 (CVA16) causes the majority of HFMD infections in the U.S. It usually occurs in children (age 10 and under), but adults can also develop the condition. This childhood disease should not be confused with the "foot and mouth disease" usually found in animals with hooves (for example, cattle, pigs, and deer). Type A viruses also cause inflammation of the eyelids and white area of the eye (conjunctivitis).

    Type B viruses cause epidemic pleurodynia (fever, lung, and abdominal pain with headache that lasts about two to 12 days and resolves). Epidemic pleurodynia is also termed Bornholm disease. There are six serotypes of coxsackie B (1-6, with B 4 considered by some researchers as a possible cause of diabetes in a number of individuals).

    Both types of viruses (A and B) can cause meningitis, myocarditis, and pericarditis, but these occur infrequently from coxsackie infections. Some researchers suggest coxsackie virus (mainly coxsackie B4) has a role in the development of acute onset type I (formerly known as juvenile) diabetes, but this relationship is still under investigation.

    Coxsackie viruses and other enteroviruses may cause the childhood disease of hand, foot, and mouth disease. However, the majority of children with coxsackie virus infections completely resolve the symptoms and infection in about 10-12 days.

    Enterovirus 71, like coxsackie virus, also causes HFMD. In Asia in July 2012, particularly Cambodia, children infected with enterovirus 71 (EV-71) had a high mortality rate. This epidemic (mainly in babies, toddlers, and children under 2 years of age) is still under intense investigation, and it is likely researchers will have a better understanding of this high death rate linked to EV-71. The research is ongoing and some investigators have suggested that mortality in children occurs from a combination of enterovirus 71, Streptococcus suis, and dengue viral coinfections. Treatment with steroids was also implicated in the disease process.

    What are coxsackie virus infection symptoms and signs?

    The most frequent signs and symptoms of coxsackie viral infections are initially fever, a poor appetite, and respiratory illness, including sore throat, cough, and malaise (feeling tired). This incubation period lasts about one to two days. Sore areas in the mouth develop in about a day or two after the initial fever and develop into small blisters that often ulcerate. Many infected people (usually children 10 years of age and younger) go on to develop a rash that itches on the palms of the hands and the soles of the feet. Other areas such as the buttocks and genitals may be involved. Some patients develop conjunctivitis. These symptoms usually last about seven to 10 days, and the person usually recovers completely. The individuals are most contagious for about a week after symptoms begin, but because the virus can be shed by the infected individual sometimes for weeks after the symptoms have gone away, the person may be mildly contagious for several weeks.

    Picture of characteristic mouth sores of hand, foot, and mouth disease (HFMD) Picture of characteristic rash and blisters of hand, foot, and mouth disease (HFMD)

    Infrequently, the infection may result in temporary fingernail or toenail loss (termed onychomadesis) and chest or abdominal muscle pain. Rarely, the disease may progress to cause viral meningitis (headache, stiff neck), myocarditis (heart muscle infection), pericarditis (inflammation/fluid collection of the tissue surrounding the heart), or encephalitis (brain inflammation).

    Infection with EV-71 results in a higher incidence of neurologic involvement with symptoms such as a polio-like syndrome, meningitis, encephalitis, Guillain-Barré syndrome, and/or ataxia.

    How do people get infected with coxsackie virus?

    Infection usually is spread by fecal-oral contamination, although occasionally the virus is spread by droplets expelled by infected individuals. Items like utensils, diaper-changing tables, and toys that come in contact with body fluids that contain the virus may also transmit them to other individuals. Although people of any age, including adults, can get infected, the majority of patients with coxsackie infection are young children. Pregnant women can pass coxsackie virus to their newborns, which may cause serious problems for the newborn. So pregnant women need to notify their obstetrician if they exhibit symptoms of the infection, especially if they are near their delivery date.

    What are the risk factors for coxsackie virus infection?

    Risk factors for coxsackie virus infection include physical contact with any patient with individuals with HFMD symptoms. Other risk factors include rural living conditions, association with children in child-care centers, and a large number of children in the family. Infectious virus can be found in feces, saliva, fluid in blisters, and nasal secretions. Even patients who have recovered and have no symptoms may still shed infectious virus for weeks. A fetus or newborn is at risk if their mother becomes infected near the delivery date. Pregnant women should avoid contact with HFMD patients. They should contact their OB/GYN physician if they develop any symptoms of HFMD.

    How are coxsackie virus infections diagnosed?

    Patients are usually diagnosed by their clinical appearance. Clinically, blisters that are painful usually on the hands, feet, and mouth in a child with fever are considered diagnostic of coxsackie virus infection. However, in rare instances, viral tests can be done to identify the virus, but the tests are expensive, usually need to be sent to a specialized viral diagnostic laboratory that uses RT-PCR, and often take about two weeks to get a result. This testing is almost never done since most infections are self-limited and typically mild, but this situation may change because of an outbreak in Alabama (38 children, 12% hospitalized but no deaths in 2011-2012) and the recent enterovirus 71 epidemic (about 905 of hospitalized children have died) in Cambodia. RT-PCR testing can distinguish between many viral genera, species, and subtypes. Distinguishing coxsackie virus strains from adenoviruses, other enterovirus types, echo virus, viruses causing mononucleosis, and other viral diseases may become necessary in the future.

    Is there any treatment for coxsackie virus infection?

    There is no specific treatment for this typically self-limited disease (the symptoms resolve without specific antiviral treatment in about two to 10 days). However, symptomatic treatment (acetaminophen [Tylenol]) that reduces fever and discomfort is currently recommended. Mouthwashes and sprays may lessen the oral discomfort. Fluids are also suggested to prevent dehydration, however, acidic juices may irritate the mouth ulcers. Cold milk may sooth the oral discomfort. Some physicians use topical diphenhydramine (Benadryl)-containing gel or liquids to treat the hand and foot discomfort.

    The relatively rare complications of coxsackie virus infections (for example, heart or brain infection) require special individualized treatments (possibly human immune globulin or specific antivirals, although such treatments are rare and not yet proved to be safe and effective with serious HFMD infections). These treatments are often administered by an infectious-disease doctor.

    Can coxsackie virus infections be prevented?

    Prevention of coxsackie virus infections is difficult but possible. With children, keeping strict hygienic precautions is almost impossible, but good practices such as hand washing after diaper changing or touching infected skin may reduce viral transmission to other family members. Attempts to regularly clean items that children contact, especially toys, pacifiers, and any items they may place in their mouths, may also reduce viral transmission. Hand washing, in general, is the best prevention technique. Currently, there is no commercial vaccine available.

    Pregnant women should avoid contact with children (or adults) with HFMD because some studies suggest that coxsackie virus may cause developmental and other defects in the fetus.

    Although infection and resolution of the disease usually renders the person immune to reinfection with the viral type that initiated the disease, the person is not immune to other coxsackie viral types. For example, a person may become immune to coxsackie viral type B4 but still would be susceptible to all of the other coxsackie viral types (for example, CVA16). In addition, other viruses such as enterovirus 71 and enteric cytopathic human orphan (ECHO) viruses can produce HFMD symptoms. Consequently, it is possible for some people to have multiple infections with HFMD symptoms even though repeated infections occur infrequently.

    In 2014, Chinese scientists have reported a successful phase 3 vaccine trial for prevention of EV-71 infections in infants and children. However, this vaccine is still considered experimental and is not commercially available to date (July 2014).

    What are the types of coxsackie viruses, and what can they cause?

    Coxsackie viruses are separable into two groups, A (CVA) and B (CVB), which are based on their effects on newborn mice (coxsackie A results in muscle injury, paralysis, and death; coxsackie B results in organ damage but less severe outcomes.) There are over 24 different serotypes of the virus (having distinct proteins on the viral surface). Coxsackie viruses infect host cells and cause host cells to break open (lyse).

    Picture of the coxsackie virus; SOURCE: CDC

    Type A viruses cause herpangina (painful blisters in the mouth, throat, hands, feet, or in all these areas). Hand, foot, and mouth disease (HFMD) is the common name of this viral infection. Coxsackie A 16 (CVA16) causes the majority of HFMD infections in the U.S. It usually occurs in children (age 10 and under), but adults can also develop the condition. This childhood disease should not be confused with the "foot and mouth disease" usually found in animals with hooves (for example, cattle, pigs, and deer). Type A viruses also cause inflammation of the eyelids and white area of the eye (conjunctivitis).

    Type B viruses cause epidemic pleurodynia (fever, lung, and abdominal pain with headache that lasts about two to 12 days and resolves). Epidemic pleurodynia is also termed Bornholm disease. There are six serotypes of coxsackie B (1-6, with B 4 considered by some researchers as a possible cause of diabetes in a number of individuals).

    Both types of viruses (A and B) can cause meningitis, myocarditis, and pericarditis, but these occur infrequently from coxsackie infections. Some researchers suggest coxsackie virus (mainly coxsackie B4) has a role in the development of acute onset type I (formerly known as juvenile) diabetes, but this relationship is still under investigation.

    Coxsackie viruses and other enteroviruses may cause the childhood disease of hand, foot, and mouth disease. However, the majority of children with coxsackie virus infections completely resolve the symptoms and infection in about 10-12 days.

    Enterovirus 71, like coxsackie virus, also causes HFMD. In Asia in July 2012, particularly Cambodia, children infected with enterovirus 71 (EV-71) had a high mortality rate. This epidemic (mainly in babies, toddlers, and children under 2 years of age) is still under intense investigation, and it is likely researchers will have a better understanding of this high death rate linked to EV-71. The research is ongoing and some investigators have suggested that mortality in children occurs from a combination of enterovirus 71, Streptococcus suis, and dengue viral coinfections. Treatment with steroids was also implicated in the disease process.

    What are coxsackie virus infection symptoms and signs?

    The most frequent signs and symptoms of coxsackie viral infections are initially fever, a poor appetite, and respiratory illness, including sore throat, cough, and malaise (feeling tired). This incubation period lasts about one to two days. Sore areas in the mouth develop in about a day or two after the initial fever and develop into small blisters that often ulcerate. Many infected people (usually children 10 years of age and younger) go on to develop a rash that itches on the palms of the hands and the soles of the feet. Other areas such as the buttocks and genitals may be involved. Some patients develop conjunctivitis. These symptoms usually last about seven to 10 days, and the person usually recovers completely. The individuals are most contagious for about a week after symptoms begin, but because the virus can be shed by the infected individual sometimes for weeks after the symptoms have gone away, the person may be mildly contagious for several weeks.

    Picture of characteristic mouth sores of hand, foot, and mouth disease (HFMD) Picture of characteristic rash and blisters of hand, foot, and mouth disease (HFMD)

    Infrequently, the infection may result in temporary fingernail or toenail loss (termed onychomadesis) and chest or abdominal muscle pain. Rarely, the disease may progress to cause viral meningitis (headache, stiff neck), myocarditis (heart muscle infection), pericarditis (inflammation/fluid collection of the tissue surrounding the heart), or encephalitis (brain inflammation).

    Infection with EV-71 results in a higher incidence of neurologic involvement with symptoms such as a polio-like syndrome, meningitis, encephalitis, Guillain-Barré syndrome, and/or ataxia.

    How do people get infected with coxsackie virus?

    Infection usually is spread by fecal-oral contamination, although occasionally the virus is spread by droplets expelled by infected individuals. Items like utensils, diaper-changing tables, and toys that come in contact with body fluids that contain the virus may also transmit them to other individuals. Although people of any age, including adults, can get infected, the majority of patients with coxsackie infection are young children. Pregnant women can pass coxsackie virus to their newborns, which may cause serious problems for the newborn. So pregnant women need to notify their obstetrician if they exhibit symptoms of the infection, especially if they are near their delivery date.

    What are the risk factors for coxsackie virus infection?

    Risk factors for coxsackie virus infection include physical contact with any patient with individuals with HFMD symptoms. Other risk factors include rural living conditions, association with children in child-care centers, and a large number of children in the family. Infectious virus can be found in feces, saliva, fluid in blisters, and nasal secretions. Even patients who have recovered and have no symptoms may still shed infectious virus for weeks. A fetus or newborn is at risk if their mother becomes infected near the delivery date. Pregnant women should avoid contact with HFMD patients. They should contact their OB/GYN physician if they develop any symptoms of HFMD.

    How are coxsackie virus infections diagnosed?

    Patients are usually diagnosed by their clinical appearance. Clinically, blisters that are painful usually on the hands, feet, and mouth in a child with fever are considered diagnostic of coxsackie virus infection. However, in rare instances, viral tests can be done to identify the virus, but the tests are expensive, usually need to be sent to a specialized viral diagnostic laboratory that uses RT-PCR, and often take about two weeks to get a result. This testing is almost never done since most infections are self-limited and typically mild, but this situation may change because of an outbreak in Alabama (38 children, 12% hospitalized but no deaths in 2011-2012) and the recent enterovirus 71 epidemic (about 905 of hospitalized children have died) in Cambodia. RT-PCR testing can distinguish between many viral genera, species, and subtypes. Distinguishing coxsackie virus strains from adenoviruses, other enterovirus types, echo virus, viruses causing mononucleosis, and other viral diseases may become necessary in the future.

    Is there any treatment for coxsackie virus infection?

    There is no specific treatment for this typically self-limited disease (the symptoms resolve without specific antiviral treatment in about two to 10 days). However, symptomatic treatment (acetaminophen [Tylenol]) that reduces fever and discomfort is currently recommended. Mouthwashes and sprays may lessen the oral discomfort. Fluids are also suggested to prevent dehydration, however, acidic juices may irritate the mouth ulcers. Cold milk may sooth the oral discomfort. Some physicians use topical diphenhydramine (Benadryl)-containing gel or liquids to treat the hand and foot discomfort.

    The relatively rare complications of coxsackie virus infections (for example, heart or brain infection) require special individualized treatments (possibly human immune globulin or specific antivirals, although such treatments are rare and not yet proved to be safe and effective with serious HFMD infections). These treatments are often administered by an infectious-disease doctor.

    Can coxsackie virus infections be prevented?

    Prevention of coxsackie virus infections is difficult but possible. With children, keeping strict hygienic precautions is almost impossible, but good practices such as hand washing after diaper changing or touching infected skin may reduce viral transmission to other family members. Attempts to regularly clean items that children contact, especially toys, pacifiers, and any items they may place in their mouths, may also reduce viral transmission. Hand washing, in general, is the best prevention technique. Currently, there is no commercial vaccine available.

    Pregnant women should avoid contact with children (or adults) with HFMD because some studies suggest that coxsackie virus may cause developmental and other defects in the fetus.

    Although infection and resolution of the disease usually renders the person immune to reinfection with the viral type that initiated the disease, the person is not immune to other coxsackie viral types. For example, a person may become immune to coxsackie viral type B4 but still would be susceptible to all of the other coxsackie viral types (for example, CVA16). In addition, other viruses such as enterovirus 71 and enteric cytopathic human orphan (ECHO) viruses can produce HFMD symptoms. Consequently, it is possible for some people to have multiple infections with HFMD symptoms even though repeated infections occur infrequently.

    In 2014, Chinese scientists have reported a successful phase 3 vaccine trial for prevention of EV-71 infections in infants and children. However, this vaccine is still considered experimental and is not commercially available to date (July 2014).

    Source: http://www.rxlist.com

    The most frequent signs and symptoms of coxsackie viral infections are initially fever, a poor appetite, and respiratory illness, including sore throat, cough, and malaise (feeling tired). This incubation period lasts about one to two days. Sore areas in the mouth develop in about a day or two after the initial fever and develop into small blisters that often ulcerate. Many infected people (usually children 10 years of age and younger) go on to develop a rash that itches on the palms of the hands and the soles of the feet. Other areas such as the buttocks and genitals may be involved. Some patients develop conjunctivitis. These symptoms usually last about seven to 10 days, and the person usually recovers completely. The individuals are most contagious for about a week after symptoms begin, but because the virus can be shed by the infected individual sometimes for weeks after the symptoms have gone away, the person may be mildly contagious for several weeks.

    Source: http://www.rxlist.com

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