eMedicine Specialties > Infectious Diseases > Viral Infections

Enteroviruses: Follow-up

Author: Smeeta Sinha, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School
Coauthor(s): Rajendra Kapila, MD, MBBS, Associate Professor, Department of Medicine, UMDNJ, New Jersey Medical School; Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Pratibha Dua, MD, MBBS, Staff Physician, Department of Internal Medicine, The Brooklyn Hospital Center; Leonard B Berkowitz, MD, Chief, Divisions of Infectious Diseases and HIV/AIDS Services, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, State University of New York at Brooklyn
Contributor Information and Disclosures

Updated: Aug 1, 2006

Follow-up

Inpatient & Outpatient Medications

  • Pleconaril is a drug that interferes with Enterovirus attachment and uncoating by binding to the virus protein capsid. It was the most promising candidate for the treatment of Enterovirus infections because of its oral bioavailability, penetration into the CNS, and efficacy in reducing the duration of symptoms and morbidity in neonatal sepsis and adult meningitis. It had been used on a compassionate basis until 2003, when the US Food and Drug Administration (FDA) declined its license. Pleconaril is currently being investigated for intranasal treatment of rhinovirus infections.
  • Immunoglobulins have been used therapeutically with some success for severe Enterovirus infections in neonates and immunocompromised hosts. Preexposure prophylaxis with immunoglobulins reduces the risk of paralysis in patients with poliovirus infections.

Deterrence/Prevention

  • Hygienic measures such as hand washing and adequate disposal of infected secretions help prevent the spread of enteroviral infections.
  • Poliovirus vaccines have been instrumental in the effort to eradicate polio; the vaccine is available in 2 forms.
    • The OPV is a live attenuated vaccine that contains all 3 serotypes. It was developed by Sabin. OPV administration decreases replication of the virus in the small intestine and increases production of high titers of IgA in the mucosa. The advantages of OPV include easy administration, stimulation of local and generalized immunity, and herd immunity. Adverse effects include vaccine-associated paralytic poliomyelitis. OPV should not be administered to patients who are immunocompromised or to household contacts of these patients.
    • The IPV was originally developed by Salk in 1955. Current formulations of IPV are more immunogenic than those available before 1987. This vaccine elicits higher IgG antibody titers and has no adverse effects. It is the recommended polio vaccine in United States.
  • The spread of acute hemorrhagic conjunctivitis is prevented by hand washing and using separate towels.

Complications

  • Polio
    • Respiratory failure secondary to paralysis of respiratory muscles or to lesions of the respiratory center is a life-threatening complication of paralytic polio.
    • Pharyngeal paralysis may occur.
    • Myocarditis is rarely diagnosed clinically.
    • Gastrointestinal hemorrhage results from intestinal erosions and may require transfusion. Gastric dilation is abrupt in onset, and immediate gastric aspiration should be performed.
    • Hypertension is a common complication and may progress to hypertensive encephalopathy.
    • The postpolio syndrome occurs 3-4 decades after acute paralytic polio. It is characterized by muscle pain, worsening of prior weakness, or new paralysis. This is more common in females than in males.
    • Vaccine-associated poliomyelitis occurs in approximately 1 per 2.6 million people overall and in 1 per 750,000 people who receive the OPV.
  • Aseptic meningitis: Complications include lethargy, febrile seizures, and coma.
  • Myopericarditis
    • Dilated cardiomyopathy may develop as a result of past enteroviral infections.
    • Rarely, chronic constrictive pericarditis may develop 5 weeks to 1 year after resolution.
  • Acute hemorrhagic conjunctivitis
    • Secondary bacterial infection may occur.
    • Motor paralysis may follow AHC by 2-5 weeks. It is clinically indistinguishable from polio, although it occurs exclusively in patients older than 20 years. Males are affected more frequently than females.
    • Neurological complications occur in epidemics caused by Enterovirus 70 but not by coxsackievirus A24.

Prognosis

  • Polio: Paralytic polio leads to permanent weakness in the affected limb. Postpolio syndrome is slowly progressive.
  • Aseptic meningitis: Fever and signs of meningeal irritation resolve within 1 week. Long-term prognosis is excellent.
  • Pleurodynia: Patients with epidemic pleurodynia completely recover.
  • Myopericarditis: The prognosis is good, and mortality rates in acute infection are low. Severe cases can result in dilated or restrictive cardiomyopathy. Twenty percent of patients may have recurrent myopericarditis.

Patient Education

  • HFM disease is very contagious, particularly from 2 days before to 2 days after the rash; however, isolation is not necessary.

Miscellaneous

Medicolegal Pitfalls

  • Avoid the nosocomial spread of AHC, particularly in ophthalmology clinics, where AHC can be spread by infected fingers or instruments.

Special Concerns

  • In contrast with other viruses, intact humoral immunity is required for the eradication of Enterovirus infection. Children with primary immunodeficiency disease are at an increased risk of chronic enteroviral infections, and they may also develop paralytic polio from the OPV.
  • Enteroviruses and insulin-dependent diabetes mellitus (type 1 DM): Many studies have evaluated the role of Enterovirus infections (particularly coxsackieviruses B4 and B5) as environmental triggers of insulin-dependent diabetes mellitus. Although a causal association has not been established, Enterovirus infection may increase susceptibility or hasten the onset of type 1 DM in children with impaired immunity or autoimmunity to pancreatic beta cells.
  • Enteroviruses and coronary heart disease (CHD): Research suggests that Enterovirus infection may increase the risk of CHD and myocardial infarction in men with normal cholesterol levels.
 


More on Enteroviruses

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

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Further Reading

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Keywords

Enterovirus, enteroviral infections, Bornholm disease, Bornholm's disease, epidemic myalgia, Sylvest's disease, Sylvest disease, devil's grip, polio, poliovirus, coxsackievirus group A, coxsackievirus group B, echovirus, aseptic meningitis, poliomyelitis, viral heart disease, hand foot and mouth disease, hand-foot-and-mouth disease, HFM disease, hemorrhagic conjunctivitis, herpangina, pleurodynia, myocarditis, pericarditis, meningoencephalitis, common cold, aseptic meningitis, acute hemorrhagic conjunctivitis, AHC, viremia, myopericarditis, abortive polio, nonparalytic polio, paralytic polio

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Contributor Information and Disclosures

Author

Smeeta Sinha, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School
Smeeta Sinha, MD is a member of the following medical societies: Alpha Omega Alpha, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Rajendra Kapila, MD, MBBS, Associate Professor, Department of Medicine, UMDNJ, New Jersey Medical School
Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Pratibha Dua, MD, MBBS, Staff Physician, Department of Internal Medicine, The Brooklyn Hospital Center
Pratibha Dua, MD, MBBS is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Leonard B Berkowitz, MD, Chief, Divisions of Infectious Diseases and HIV/AIDS Services, Brooklyn Hospital Center; Clinical Assistant Professor, Department of Medicine, State University of New York at Brooklyn
Leonard B Berkowitz, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Mary Nettleman, MD, MS, Chair, Department of Medicine, Michigan State University
Mary Nettleman, MD, MS is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Ronald A Greenfield, MD, Professor, Chief, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubicin  Speaking and teaching

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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