eMedicine Specialties > Infectious Diseases > Viral Infections

Coxsackieviruses: Differential Diagnoses & Workup

Author: Michael Rajnik, MD, Assistant Professor, Department of Pediatrics, Acting Program Director, Pediatric Infectious Disease Fellowship Program, Uniformed Services University of the Health Sciences
Coauthor(s): Nhat M Doan, MD, Fellow, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center
Contributor Information and Disclosures

Updated: Jun 30, 2008

Differential Diagnoses

Ependymoma

Other Problems to Be Considered

Aseptic meningitis

Encephalitis
  • Arboviruses
  • Herpes simplex virus (HSV)
  • Lymphocytic choriomeningitis virus
Myopericarditis
Exanthems
  • HFM disease
    • Herpes simplex: Patients are more ill, have higher fever and cervical adenopathy, and have no lesions on extremities.
    • VZV: Patients are also more ill, rarely have oral lesions, and the palms of the hands and soles of the feet are rarely affected.
  • Herpangina
    • Other viral causes of pharyngitis and bacterial tonsillitis: These do not produce vesicular lesions.
    • Primary herpetic gingivostomatitis: Gingivitis is prominent, and systemic toxicity and cervical lymphadenitis are present; scrapings of lesions do not reveal giant cells or intranuclear inclusions.
    • HFM disease: These lesions also occur on extremities.
    • Aphthous stomatitis: Lesions tend to be larger and occur in older children and adults.
Epidemic pleurodynia
Acute hemorrhagic conjunctivitis
  • Adenovirus causing keratoconjunctivitis: The incubation period is 1-3 weeks, whereas the incubation period is 1 day with acute hemorrhagic conjunctivitis (AHC). In addition, subconjunctival hemorrhage is usually not observed with keratoconjunctivitis.
  • Bacterial or chlamydial conjunctivitis must be considered, but these conditions usually do not cause an extensive outbreak.

Workup

Laboratory Studies

Definitive diagnosis can be made based on isolation of the virus in cell culture. Cytopathic effect can usually be seen within 2-6 days. Samples are normally taken from the stool or rectal swabs but may be isolated from the oropharynx early in the disease course. False-positive culture results are possible, as excretion can occur for up to 8 weeks after initial infection. Serology can be difficult to interpret. Traditionally, enteroviral infections have been noted after a rise in neutralizing antibodies titer (at least a 4-fold rise in titer between acute and convalescent phase). PCR is also available, with a sensitivity of 66-90%.

  • Aseptic meningitis: The workup needs to rule out bacterial meningitis, and appropriate antibiotics should be administered until the workup is complete. Diagnosis requires cerebrospinal fluid (CSF) evaluation, which tends to show a lymphocytic predominance, normal-to-decreased glucose levels, and normal-to-slightly elevated protein levels. The virus can be isolated via cell culture (sensitivity, 30-35%) or PCR (sensitivity, 66-90%). A recent study in infants reported that routine CSF PCR for enteroviruses resulted in shorter hospital stays (by 1.54 days) and a decreased duration of antibiotic use (by 33%).2
  • Encephalitis: Diagnostic workup requires CSF evaluation, which yields findings similar to those of aseptic meningitis.
  • Myopericarditis: Diagnosis is generally circumstantial, with evidence of infection from the oropharynx, feces, or on serology.
  • Acute hemorrhagic conjunctivitis (AHC): Diagnosis requires conjunctival swabs or scrapings, which are 90% successful. A rising antibody titer can be demonstrated.

Imaging Studies

  • Head CT scanning without contrast may be obtained upon initial presentation of meningitis and/or encephalitis to rule out hemorrhage, increased intracranial pressure, or mass lesions.
  • Echocardiography can be used to evaluate overall cardiac function and valvular disease in patients with myopericarditis and heart failure.

Other Tests

  • Obtain a throat culture to rule out streptococcal pharyngitis and/or tonsillitis.
  • HIV testing is always appropriate in patients who present with nonspecific febrile illness or rashes.
  • An EEG can be used to detect the presence of and localize seizure activity.
  • ECG changes in myopericarditis include ST-segment elevations or nonspecific ST segment, T-wave abnormalities, arrhythmia, and heart block.

Procedures

  • Lumbar puncture is crucial in the evaluation of meningitis and/or encephalitis.
  • Skin biopsy may be helpful in the evaluation of nonspecific exanthems.
  • Obtain a Tzank smear to rule out herpes virus infection.

Histologic Findings

Intracytoplasmic viral particles may be observed, especially with skin lesions and/or rashes of HFM.

More on Coxsackieviruses

Overview: Coxsackieviruses
Differential Diagnoses & Workup: Coxsackieviruses
Treatment & Medication: Coxsackieviruses
Follow-up: Coxsackieviruses
References
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References

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Further Reading

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Keywords

coxsackieviruses, coxsackie viruses, coxsackie virus A, coxsackievirus A, hand-foot-and-mouth disease, hand-foot-mouth disease, HFM disease, vesicular stomatitis with exanthem, coxsackievirus B, coxsackie virus B, Bamle disease, Bornholm disease, Daae disease, Sylvest disease, benign dry pleurisy, epidemic pleurodynia, devil's grip, devil's grippe, diaphragmatic pleurisy, epidemic benign dry pleurisy, epidemic diaphragmatic pleurisy, epidemic myalgia, epidemic myositis, myositis epidemica acuta, epidemic transient diaphragmatic spasm, aseptic meningitis, acute hemorrhagic conjunctivitis, AHC, enteroviral infection,

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Contributor Information and Disclosures

Author

Michael Rajnik, MD, Assistant Professor, Department of Pediatrics, Acting Program Director, Pediatric Infectious Disease Fellowship Program, Uniformed Services University of the Health Sciences
Michael Rajnik, MD is a member of the following medical societies: American Academy of Pediatrics, Armed Forces Infectious Diseases Society, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Coauthor(s)

Nhat M Doan, MD, Fellow, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center
Nhat M Doan, MD is a member of the following medical societies: American Medical Association and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Maria D Mileno, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John W King, MD, Professor of Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center; Director, Viral Therapeutics Clinics for Hepatitis; Consulting Staff, Department of Infectious Diseases, Overton Brook Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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