Norwalk Virus Workup

  • Author: Zartash Zafar Khan, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 11, 2012
 

Laboratory Studies

  • Generally, routine laboratory studies are not helpful in suspected cases of norovirus gastroenteritis. In severe cases of gastroenteritis with volume depletion, electrolytes and blood urea nitrogen and creatinine should be monitored.
  • The peripheral white blood cell count is usually normal. There may be slight polymorphonuclear leucocytosis and lymphopenia.
  • The absence of fecal leucocytes and occult blood in stool is helpful in ruling out other enteroinvasive infectious diarrhea processes. Stool culture should be performed to exclude infection with bacterial organisms such as Yersinia, Shigella, Salmonella, and Campylobacter species.[17]
  • Detection methods include the following:
    • Immune electron microscopy: Immune serum is used to aggregate virus in stool samples to aid detection.
    • Antigen detection immune assay: This has high sensitivity but low specificity because of reactivity with antigenic variants and homologous viruses.
    • Nucleic acid amplification: This technique is highly sensitive and specific. The sensitivity of real-time polymerase chain reaction (RT-PCR) is more than 1000 times greater than that of standard enzyme-linked immunosorbent assays and approximately 10-fold greater than reverse-transcription PCR in detection of norovirus capsid proteins in stool and food samples.[18]
    • Serum antibody titers can be detected within 2 weeks of illness. During norovirus infection, immunoglobulin M (IgM) to norovirus has been found to be more specific than IgG.[19]
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Imaging Studies

  • Imaging for isolated uncomplicated gastroenteritis is not required.
  • In patients with severe symptoms in whom acute abdomen is suspected and in those with pre-existing diseases such as inflammatory bowel disease or other comorbidities, abdominal radiography or CT scanning should be performed.
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Other Tests

  • If the patient is an international traveler, stool testing for ova and parasites and stool culture should be considered.
  • If the patient is severely immunocompromised (eg, with AIDS), stool tests for Cyclospora, cytomegalovirus (CMV), Isospora, and Cryptosporidium may be considered.
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Histologic Findings

The surface area of the villus is reduced (villus blunting), along with the appearance of a dense intraepithelial infiltrate of CD8+ T lymphocytes. An increase in polymononuclear cells in the lamina propria of the small intestine is also observed.

In one study, electrophysiological analyses of duodenal biopsies from patients with norovirus infected showed increased epithelial apoptosis and a reduction in tight junctional protein expression, leading to epithelial barrier dysfunction. This likely contributes to diarrhea during norovirus infection by a leak flux mechanism (ie, ions and water leak from subepithelial capillaries into the intestinal lumen by paracellular diffusion due to increased permeability of tight junctions). Increased anion secretion was another finding in the study.[9] See the image below.

Hematoxylin and eosin stain of duodenal epitheliumHematoxylin and eosin stain of duodenal epithelium.
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Contributor Information and Disclosures
Author

Zartash Zafar Khan, MD  Infectious Disease Consultant

Zartash Zafar Khan, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and International Society for Infectious Diseases

Disclosure: Nothing to disclose.

Coauthor(s)

Mark Martin Huycke, MD  Professor of Medicine, Infectious Diseases Section, University of Oklahoma Health Sciences Center; Chief, Medical Service, Department of Veterans Affairs Medical Center, Oklahoma City

Mark Martin Huycke, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Todd S Wills  MD, Associate Professor, Department of Medicine, Division of Infectious Disease and International Medicine, Program Director, Infectious Disease Fellowship Program, University of South Florida College of Medicine

Todd S Wills is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Michelle A Jaworski  MD, Consulting Staff, Midland Orthopedic Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph Richard Masci, MD  Professor of Medicine, Professor of Preventive Medicine, Mount Sinai School of Medicine; Director of Medicine, Elmhurst Hospital Center

Joseph Richard Masci, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Association of Professors of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Richard B Brown, MD, FACP  Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

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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Hematoxylin and eosin stain of duodenal epithelium.
The norovirus genomic structure and capsid domains.
 
 
 
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