Summary
Coxsackieviruses are RNA nonpolio enteroviruses that are part of the Picornoviridae family. There are over 20 serotypes divided into groups A and B. Clinical manifestations due to coxsackievirus infection vary based on group and serotype. Group A coxsackieviruses more commonly cause hand, food, and mouth disease (HFMD); herpangina; and conjunctivitis, whereas group B coxsackieviruses more commonly cause pleurodynia, dilated cardiomyopathy, myocarditis, and pericarditis. Both groups can manifest with flu-like illness and cause various conditions, including meningitis, encephalitis, and respiratory illness (e.g., pneumonia). Most patients with coxsackievirus infection are diagnosed clinically; PCR confirms the diagnosis in case of diagnostic uncertainty or severe disease. Treatment is individualized according to symptoms; antiviral agents are not routinely recommended but may be considered by a specialist for severe infection (e.g., encephalitis). Coxsackieviruses are highly infectious and are mainly transmitted through airborne droplets and via fecal-oral spread; prevention includes respiratory hygiene, hand hygiene, and cleaning of contaminated surfaces and objects.
Overview
Epidemiology
- Worldwide distribution
- Occur in all age groups
- Highest incidence in infants and young children (< 10 years) [1]
Etiology
-
Pathogen: coxsackievirus
- Genus: Enterovirus
- Family: Picornaviridae
- Over 20 serotypes, divided into group A coxsackieviruses and group B coxsackieviruses
- Single‑stranded RNA virus
-
Route of transmission
- Airborne droplets
- Fecal‑oral route
- Vertical transmission
Clinical features
Coxsackievirus infections may be asymptomatic or may manifest as a wide range of diseases. [2]
- Group A coxsackieviruses more commonly cause : [3]
-
Group B coxsackieviruses more commonly cause : [4][5]
- Pleurodynia
- Viral myocarditis
- Viral pericarditis
- Dilated cardiomyopathy
-
Other manifestations include:
- Flu-like illness
- Respiratory illness (e.g., pneumonia)
- Viral meningitis
- Enteroviral encephalitis
- Infection during pregnancy
- Manifestations vary from mild to severe. [6]
- Group B coxsackievirus infection can cause fetal growth restriction and preterm labor. [7]
Group B coxsackieviruses are one of the most common causes of viral myocarditis. [8]
Hand, foot, and mouth disease and herpangina
Definition [1]
Hand, foot, and mouth disease (HFMD) and herpangina are highly contagious febrile infections most commonly caused by group A coxsackieviruses.
- HFMD manifests with a cutaneous rash and painful oral lesions.
- Herpangina manifests with painful lesions limited to the oral cavity.
Etiology [4]
-
Causative pathogen: nonpolio enteroviruses
- US and Europe: most commonly Coxsackievirus A serotypes
- Asia-Pacific: most commonly Enterovirus A71
- Incubation period: 3–6 days
Epidemiology [2][4]
- Most commonly affects children < 5 years of age
- Highest incidence in summer and fall in temperate climates
Clinical features [1][4][9]
- Fever, malaise
-
Painful oral lesions ; [1][10]
- Initially manifest as discrete small papules that develop into 1–2 mm vesicles with surrounding erythema [10]
- Enlarge over several days to form 3–4 mm ulcers that do not coalesce [10]
- Typically affect the posterior oral cavity (e.g., tonsils, uvula, soft palate, oropharynx)
- Occasionally involve the perioral area and tip of the tongue
- Cutaneous lesions: macular, papular, and partially vesicular rash
- Atypical manifestations include: [1][4]
- Coalescing lesion or rash that forms bullae
- Eczema coxsakium: a manifestation of HFMD that is characterized by accentuated eruptions in areas of active or inactive atopic dermatitis
- Hemorrhagic or purpuric lesions
Onychomadesis may occur 4–6 weeks after resolution of HFMD. [2][11]
Diagnosis [1][2][4]
- Diagnosis is usually clinical.
- Perform PCR (e.g., on stool, vesicle fluid, buccal swabs):
- In severe cases (e.g., complicated by meningitis or encephalitis)
- If there is diagnostic uncertainty
Treatment [2][4]
- Infection is self-limited; lesions begin to resolve after 7–10 days. [1][4]
- Antiviral agents are not routinely recommended. [1]
- Treatment is supportive, e.g.:
-
Acetaminophen or ibuprofen as needed for management of fever or pain [1]
- See “Supportive care for pediatric fever” for pediatric dosages; avoid aspirin in children.
- See “Antipyretics” for adult dosages.
-
Ensure adequate hydration; manage odynophagia as needed. [12]
- Offer ice cream, milk, and soft foods.
- Consider saltwater gargles.
- Rarely, admission may be required for management of dehydration. [1]
-
Acetaminophen or ibuprofen as needed for management of fever or pain [1]
- Provide education on exposure control for coxsackievirus infection.
Oral lidocaine is not recommended for odynophagia because of insufficient evidence supporting its use and the risk of poisoning. [1][13]
Differential diagnoses [1]
- Oral and perioral ulcerations
-
Cutaneous rash
- Other causes of:
- Herpes simplex virus infections (e.g., herpes gladiatorum, eczema herpeticum)
- Dermatitis (e.g., dyshidrotic eczema, contact dermatitis, atopic dermatitis)
- Rocky Mountain spotted fever
Complications [1][4]
Complications (more common in enterovirus A71 infection) include:
Pleurodynia
Definition
Pleurodynia (Bornholm disease) is an acute viral illness characterized by fever, flu-like symptoms, and painful spasms of the muscles of the chest and/or upper abdomen.
Etiology [5][14]
- Most commonly, group B coxsackieviruses
- Rarely caused by Echovirus spp. or group A coxsackieviruses
Epidemiology [14]
- Typically affects older children, adolescents, and young adults
- Rare in older adults
Clinical features [5][14]
- Fever and other flu-like symptoms (e.g., cough, sore throat, nausea, headache)
-
Episodes of sudden-onset severe, cramping thoracic and/or upper abdominal pain
- Typically last 15–30 minutes [14][15]
- Usually resolve within 4 days
- Clinical examination is usually normal; a pleural or pericardial rub may be noted. [5][15]
- Close contacts of the patient are often affected concurrently. [5]
Spasms are most common in the febrile phase of disease. [14][15]
Diagnosis [5][14]
- Pleurodynia is a diagnosis of exclusion.
- Routine studies are often normal but may reveal the following findings.
- Laboratory studies: mild elevations in WBC count, ESR, and creatine kinase
-
Diagnostic studies for chest pain:
- Chest x-ray: pulmonary infiltrates with or without pleural effusions
- ECG: T-wave inversions if there is pericardial or myocardial involvement
- Diagnostic studies for acute abdominal pain are typically normal.
- In case of diagnostic uncertainty: Obtain coxsackievirus serology or PCR. [2][14]
Treatment [14]
Symptoms are typically self-limited and resolve within days.
- Recommend supportive care with: [14][15]
- Oral analgesia
- Application of heat to the affected area
- Intercostal block can be considered for pain management. [14]
- Provide information on exposure control for coxsackievirus infection.
Differential diagnoses
Complications [2][14]
Complications are rare and include:
Prevention
Exposure control
- Hospitalized patients
- Initiate contact precautions.
- Include droplet precautions for those with respiratory symptoms.
- Advise all patients to:
- Use hand hygiene (with soap), especially after changing diapers and before meals
- Consider respiratory hygiene measures.
- Avoid close contact with infected individuals.
- Disinfect contaminated surfaces (e.g., doorknobs, toys, changing areas).
- Children with mild infections can attend school unless during an outbreak; check the local health department policy.
Fecal shedding can persist for 2–8 weeks after the onset of infection. Respiratory shedding typically lasts up to 3 weeks. [2]