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Coxsackieviruses Workup

  • Author: Martha L Muller, MD; Chief Editor: Michael Stuart Bronze, MD  more...
Updated: Aug 15, 2016

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%).[6]


Diagnostic workup requires CSF evaluation, which yields findings similar to those of aseptic meningitis.


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.



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.

Contributor Information and Disclosures

Martha L Muller, MD Associate Professor of Pediatrics, Division of Infectious Diseases, University of New Mexico School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks 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, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Maria D Mileno, MD Associate Professor of Medicine, Division of Infectious Diseases, The Warren Alpert Medical School of 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, Sigma Xi

Disclosure: Nothing to disclose.


Mashiul H Chowdhury, MD Assistant Professor, Department of Medicine, Division of Infectious Disease, Program Director, Infectious Disease Fellowship, Director, TravelHealth Center, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Nhat M Doan, MD Fellow, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center

Disclosure: Nothing to disclose.

Parul Kaushik, MD, MPH Fellow, Department of Medicine, Division of Infectious Disease, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Michael Rajnik, MD Associate Professor, Department of Pediatrics, Program Director, Pediatric Infectious Disease Fellowship Program, Uniformed Services University of the Health Sciences

Michael Rajnik is a member of the following medical societies: American Academy of Pediatrics, Armed Forces Infectious Disease Society, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society.

Disclosure: Nothing to disclose.

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