Coxsackievirus Infections

Coxsackieviruses are enteroviruses divided into group A and group B, based on historical pathogenicity patterns in laboratory animals. They cause a wide spectrum of human disease, from asymptomatic infection and mild febrile illness to recognisable syndromes. Disease occurs most commonly in children but affects all age groups.

Specific syndromes include hand, foot and mouth disease and herpangina. Of greater clinical significance are viral meningitis, myocarditis and pericarditis. Transmission is predominantly faecal oral; respiratory manifestations also spread by respiratory droplet.

Virology and clinical spectrum

Group A coxsackieviruses are classically associated with vesicular exanthems (hand, foot and mouth disease) and herpangina. Group B coxsackieviruses are more classically associated with pleurodynia, myocarditis and pericarditis.

Considerable overlap exists. Specific serotype identification rarely influences clinical management in routine practice. The clinical syndrome present at diagnosis guides management, rather than viral typing.

Hand, foot and mouth disease presents with fever and a characteristic vesicular rash affecting the palms, soles and buttocks. Painful oral vesicles and ulcers accompany it. It typically occurs in young children after a brief incubation period. The illness is generally mild and self limiting over seven to ten days. Oral pain can significantly impair oral intake in young children, occasionally requiring attention to hydration.

Herpangina presents with fever and painful vesicular lesions confined to the posterior oropharynx (soft palate, tonsillar pillars, uvula). This distinguishes it from the more anterior oral involvement and additional cutaneous features of hand, foot and mouth disease. It is similarly self limiting over several days.

Viral (aseptic) meningitis presents with fever, headache, neck stiffness and photophobia. It is a common enteroviral manifestation, particularly in children and young adults. The course is generally benign and self limiting, distinct from bacterial meningitis. Clinical distinction at presentation can be difficult and requires appropriate investigation.

Myopericarditis presents with chest pain, arrhythmia or heart failure. It is the most clinically significant potential manifestation, particularly with group B coxsackievirus infection.

Pleurodynia (Bornholm disease) is a further recognised though less common manifestation. It presents with severe, sharp, spasmodic chest or upper abdominal pain exacerbated by breathing and movement, reflecting intercostal muscle involvement.

Severe neonatal disease can follow vertical or early postnatal transmission. It includes disseminated infection with hepatitis, myocarditis and coagulopathy and carries substantial mortality. It is an uncommon severe presentation that needs a high index of suspicion in an unwell neonate.

Diagnosis of the common, self limiting mucocutaneous syndromes (hand, foot and mouth disease, herpangina) is generally clinical. It rests on the characteristic appearance and distribution of lesions. Routine virological confirmation is not needed, given the benign, self limiting course and the absence of any specific treatment that typing would influence.

Polymerase chain reaction testing provides sensitive and rapid confirmation where a specific diagnosis is required. Use an appropriate specimen: cerebrospinal fluid for suspected meningitis, throat or stool sample, or blood in severe or neonatal disease.

It is particularly relevant in suspected viral meningitis. A positive enteroviral polymerase chain reaction result on cerebrospinal fluid can support earlier, confident discontinuation of empirical antibacterial therapy. This applies once bacterial meningitis has been reasonably excluded on overall clinical and initial cerebrospinal fluid findings.

Cerebrospinal fluid analysis in enteroviral meningitis typically shows a lymphocytic pleocytosis, normal glucose, and mildly elevated protein. A neutrophil predominance can occur very early in the illness. The pattern is generally distinguishable from bacterial meningitis but needs careful clinical correlation, particularly early in the illness.

Investigate suspected myopericarditis by the standard diagnostic approach for those conditions.

Severe or neonatal disease warrants full investigation, including blood, cerebrospinal fluid and, where relevant, stool testing. Assess liver function and coagulation, given the risk of severe multisystem involvement in this population.

Management of the common mucocutaneous syndromes (hand, foot and mouth disease, herpangina) is entirely supportive.

• Maintain adequate hydration. Painful oral lesions can reduce oral intake, so encourage cool fluids and soft foods. Rarely, intravenous fluid support is needed if oral intake becomes significantly compromised.
• Give simple analgesia (paracetamol or ibuprofen at standard weight based paediatric doses) for pain and fever.
• Use topical oral analgesic preparations for symptomatic relief of oral discomfort where tolerated.

Viral meningitis is managed supportively with analgesia, antipyretics and adequate hydration. Give initial empirical antibacterial treatment until bacterial meningitis has been reasonably excluded. Exclusion rests on clinical assessment, cerebrospinal fluid findings and, where available, specific enteroviral polymerase chain reaction confirmation. Antibacterial therapy can then be confidently discontinued, given the benign, self limiting natural history of enteroviral meningitis in the great majority of cases.

No specific antiviral treatment of proven efficacy is available for coxsackievirus infection at any severity. Myopericarditis is therefore managed on the principles for those conditions, centred on supportive and, where required, specific cardiac or haemodynamic management according to severity.

Severe or neonatal disseminated disease requires intensive supportive care, addressing the specific pattern of organ involvement present: cardiac support for myocarditis, correction of coagulopathy, management of hepatic dysfunction.

Intravenous immunoglobulin is used in some protocols for severe neonatal enteroviral disease, though evidence for definitive efficacy remains limited. Pleconaril, an investigational antienteroviral agent, has shown some activity in specific severe presentations but is not widely available for routine clinical use.

Standard infection control precautions support limitation of transmission, given the significant infectivity of these viruses. These include hand hygiene and exclusion from childcare or school settings during the acute symptomatic period according to local public health guidance. They are particularly relevant in outbreak settings within childcare facilities.