eMedicine Specialties > Infectious Diseases > Viral Infections

Enteroviruses: Follow-up

Author: Alexander Velazquez, MD, Fellow, Department of Infectious Diseases, Orlando Regional Medical Center
Coauthor(s): Mark R Wallace, MD, FACP, FIDSA, Clinical Professor of Medicine, Florida State University College of Medicine; Infectious Disease Fellowship Director, Orlando Regional Medical Center; Smeeta Sinha, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School; Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School; Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Pratibha Dua, MD, MBBS, Staff Physician, Department of Internal Medicine, The Brooklyn Hospital Center
Contributor Information and Disclosures

Updated: Nov 10, 2009

Follow-up

Inpatient & Outpatient Medications

  • Pleconaril interferes with enterovirus attachment and uncoating by binding to the virus protein capsid. It was once 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, adult meningitis, and perimyocarditis; however, efficacy has not been definitively established.57,55 Until 2003, when the US Food and Drug Administration (FDA) declined its approval, pleconaril had been used on a compassionate basis for treatment of myocarditis and aseptic meningitis in infants. Pleconaril in an intranasal form is currently awaiting FDA approval for the treatment of rhinoviral infections.
  • Immunoglobulins have been used therapeutically and prophylactically for enteroviral CNS infections in neonates and immunocompromised hosts, with mixed results.58 Pre-exposure prophylaxis with immunoglobulins is known to reduce 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 poliomyelitis59 and seroconversion rates lower than those achieved with IPV. OPV should not be administered to immunocompromised patients or to household contacts of these patients.
    • OPV is used in developing nations because of it lower cost, ease of administration, and superior secretory immunity in the GI tract in comparison to IPV.
    • 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 few adverse effects but is inferior to OPV in providing secretory immunity in the GI tract. It is the recommended polio vaccine in United States when the risk of vaccine-associated paralytic polio disease due to OPV exceeds that of wild-type polio disease. Higher costs for production and supply and the delivery route, along with the lack of herd immunity, makes its use less desirable in developing countries.
    • Combined immunization with OPV and IPV provides the highest serum level of antibody response, with equivalent mucosal immunity to that produced by OPV alone.60
  • The spread of AHC 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.
    • 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 women than in men.
    • 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.
  • Nonpoliovirus paralytic disease: This is usually less severe than polio-associated paralysis.
  • Myopericarditis
    • Chronic dilated cardiomyopathy may result from past enteroviral infections, and cardiac transplantation may be required in severe cases.
    • In rare cases, chronic constrictive pericarditis develops 5 weeks to 1 year after resolution.
  • Acute hemorrhagic conjunctivitis
    • Secondary bacterial conjunctivitis may occur.
    • In severe cases, keratitis may occur and may last several weeks but is rarely permanent.
    • Paralysis (motor and/or sensory) 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.61
    • Neurological complications of AHC occur in epidemics caused by enterovirus 70 but not by coxsackievirus A24.

Prognosis

  • Polio: Paralytic polio leads to permanent weakness in the affected limb. Permanent weakness occurs in approximately two thirds of patients. Postpolio syndrome is slowly progressive. In the epidemic era, poliomyelitis carried an overall mortality rate of 5%-10%.
  • Aseptic meningitis: Fever and signs of meningeal irritation usually resolve within 1-2 weeks in infants; some adults are ill for 2-3 weeks. 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, persistent electrocardiographic abnormalities, or congestive heart failure. Twenty percent of patients may have recurrent myopericarditis and develop chronic dilated cardiomyopathy. Infants are at a higher risk of developing long-term sequelae.

Patient Education

  • HFMD is very contagious, especially during the first week of the illness. The virus can still be spread weeks after symptoms have resolved. As a preventive measure, close contact with affected individuals should be avoided.

Miscellaneous

Medicolegal Pitfalls

  • Avoid the nosocomial spread of AHC, particularly in ophthalmology clinics, where AHC can be spread by infected fingers or instruments.
  • Do not mistake tuberculous meningitis or brain abscess for aseptic meningitis.
  • Patients with myopericarditis who also have traditional risk factors for ischemic heart disease should undergo risk stratification and an appropriate cardiac workup.

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 for chronic enteroviral infections, such as a chronic meningoencephalitis, and may also develop paralytic polio from the OPV.62 IVIG and pleconaril in the treatment of chronic meningoencephalitis have been ineffective.55
  • Enteroviruses and insulin-dependent diabetes mellitus: Many studies have evaluated the role of enterovirus infections (particularly coxsackieviruses B4 and B5) as environmental triggers of insulin-dependent diabetes mellitus. Although a definite causal association has not been established, enterovirus infection may increase susceptibility or hasten the onset of insulin-dependent diabetes mellitus in children with impaired immunity or autoimmunity to pancreatic beta cells.63,64
  • 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.
  • Cases and small outbreaks of enterovirus infections in bone marrow transplant recipients have been reported, contributing to some deaths.65 However, the exact mechanism of these viruses in the posttransplant period is unknown. Further studies are needed.66
 


More on Enteroviruses

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

Alexander Velazquez, MD, Fellow, Department of Infectious Diseases, Orlando Regional Medical Center
Alexander Velazquez, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Mark R Wallace, MD, FACP, FIDSA, Clinical Professor of Medicine, Florida State University College of Medicine; Infectious Disease Fellowship Director, Orlando Regional Medical Center
Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

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.

Rajendra Kapila, MD, MBBS, Professor of Medicine, 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, Dermatology, Professor of Pathology, Pediatrics, Medicine, and 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.

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, Association of Professors of Medicine, 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: eMedicine Salary Employment

Managing Editor

Ronald A Greenfield, MD, Professor, 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; Cubist  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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