- Author: Irina Petrache, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Pleurodynia is an uncommon complication of coxsackievirus B infection. However, cases of pleurodynia secondary to other enteroviruses have been reported (eg, cytopathogenic human orphan [ECHO] virus). Pleurodynia is defined as the sudden occurrence of lancinating chest pain or abdominal pain attacks, commonly associated with fever, malaise, and headaches. Coxsackievirus B is an RNA Enterovirus, which usually causes an asymptomatic or brief upper respiratory tract or gastroenteric infection. In rare cases, other severe sequelae of coxsackievirus B infection develop, including meningitis and carditis.
Also see the article Coxsackieviruses.
The striated muscle is the actual anatomic structure targeted by the coxsackievirus B and is responsible for the attacks of severe chest pain. Therefore, the term pleurodynia may be a misnomer because only some patients with the condition actually develop pleuritis (ie, inflammation of the pleural surface). In patients with pleurodynia, the striated intercostal muscles necrose, which explains the frequent elevations in serum creatine kinase levels. Some of the more chronic sequelae, such as myocarditis, dermato-polymyositis, chronic fatigue syndrome, and possibly, juvenile-onset diabetes type I, are believed to be immune mediated.
The virus has an incubation time of 1 week in the gastrointestinal tract and then, through hematogenous dissemination, involves the target organs, most commonly the skeletal muscles but also the CNS (ie, meningitis, encephalitis) and myocardium (ie, carditis with or without associated pericarditis). Coxsackievirus B can be recovered in the stool or pharynx for up to 2 weeks after the resolution of the symptoms.
Coxsackievirus B was present in 24% of the 18,000 enteroviruses isolated and reported in the United States from 1970-1979. The estimated number of nonpolio enteroviral symptomatic infections is 5-10 million per year.
In regions of temperate climate, the infection is seasonal, with about 90% of infections occurring in the summer and early fall, and sometimes infections occur in epidemics.
The incidence of coxsackievirus B infection in neonates is 1 in 2000 live births.
Antibodies to coxsackievirus B serotypes are present in 75% of the population in developed countries. In the tropical and subtropical climate areas, the prevalence of the enteroviral infections is year-round.
The severity of the coxsackievirus B infection is highest in infants and children. In infants who develop coxsackievirus B infection, 10% die, usually within the first 4 weeks of life most commonly from cardiac involvement. Fulminant hepatic failure, sepsis syndrome, and severe CNS involvement with seizures and apnea are also potential complications in this age group.
Males are more commonly affected than females.
Coxsackievirus B infection occurs most commonly in children younger than 15 years; half of these patients are younger than 5 years, and 30% are younger than 1 year. The disease is rare in patients older than 60 years. However, pleurodynia most commonly affects adults infected with the virus, with fewer than 10% of cases occurring in patients younger than 20 years. Of the 372 prospectively studied children aged 4-18 years with nonpolio enteroviral infections, only 3% developed pleurodynia. In contrast, 30 of the 78 mostly adult patients with coxsackievirus B-associated cardiac disease had pleurodynia. Therefore, the location of pain is believed to be predominantly thoracic in adults and abdominal in children.
The prognosis is good, with complete recovery in most cases. The return to normal health may be gradual after a period of weakness and fatigue. No deaths are reported as a direct result of pleurodynia.
Bell EJ, Grist NR. ECHO viruses, carditis, and acute pleurodynia. Am Heart J. 1971 Jul. 82(1):133-5. [Medline].
Moore M, Kaplan MH, McPhee J, Bregman DJ, Klein SW. Epidemiologic, clinical, and laboratory features of Coxsackie B1-B5 infections in the United States, 1970-79. Public Health Rep. 1984 Sep-Oct. 99(5):515-22. [Medline]. [Full Text].
Kaplan MH, Klein SW, McPhee J, Harper RG. Group B coxsackievirus infections in infants younger than three months of age: a serious childhood illness. Rev Infect Dis. 1983 Nov-Dec. 5(6):1019-32. [Medline].
Mizuta K, Yamakawa T, Nagasawa H, Itagaki T, Katsushima F, Katsushima Y, et al. Epidemic myalgia associated with human parechovirus type 3 infection among adults occurs during an outbreak among children: findings from Yamagata, Japan, in 2011. J Clin Virol. 2013 Sep. 58 (1):188-93. [Medline].
Rotbart HA, Sawyer MH, Fast S, et al. Diagnosis of enteroviral meningitis by using PCR with a colorimetric microwell detection assay. J Clin Microbiol. 1994 Oct. 32(10):2590-2. [Medline]. [Full Text].
Romero JR. Reverse-transcription polymerase chain reaction detection of the enteroviruses. Arch Pathol Lab Med. 1999 Dec. 123(12):1161-9. [Medline].
Nolte FS. Case studies in cost effectiveness of molecular diagnostics for infectious diseases: pulmonary tuberculosis, enteroviral meningitis, and BK virus nephropathy. Clin Infect Dis. 2006 Dec 1. 43(11):1463-7. [Medline].
Noordhoek GT, Weel JF, Poelstra E, Hooghiemstra M, Brandenburg AH. Clinical validation of a new real-time PCR assay for detection of enteroviruses and parechoviruses, and implications for diagnostic procedures. J Clin Virol. 2008 Feb. 41(2):75-80. [Medline].
Patel DD, Kapoor A, Ayyagari A, Dhole TN. Development of a simple restriction fragment length polymorphism assay for subtyping of coxsackie B viruses. J Virol Methods. 2004 Sep 15. 120(2):167-72. [Medline].
Jaianand K, Saravanan N, Gunasekaran P, Sheriff AK. Development of a new method for diagnosis of Group B Coxsackie genome by reverse transcription loop-mediated isothermal amplification. Indian J Med Microbiol. 2011 Apr-Jun. 29(2):110-7. [Medline].
McCartney RA, Banatvala JE, Bell EJ. Routine use of mu-antibody-capture ELISA for the serological diagnosis of Coxsackie B virus infections. J Med Virol. 1986 Jul. 19(3):205-12. [Medline].
Roehrig JT, Hombach J, Barrett AD. Guidelines for Plaque-Reduction Neutralization Testing of Human Antibodies to Dengue Viruses. Viral Immunol. 2008 Jun. 21 (2):123-32. [Medline].
Coates HV, Alling DW, Chanock RM. An antigenic analysis of respiratory syncytial virus isolates by a plaque reduction neutralization test. Am J Epidemiol. 1966 Mar. 83 (2):299-313. [Medline].
Yang L, He D, Tang M, Li Z, Liu C, Xu L, et al. Development of an enzyme-linked immunosorbent spot assay to measure serum-neutralizing antibodies against coxsackievirus B3. Clin Vaccine Immunol. 2014 Mar. 21 (3):312-20. [Medline].
Miteva K, Haag M, Peng J, Savvatis K, Becher PM, Seifert M. Human cardiac-derived adherent proliferating cells reduce murine acute Coxsackievirus B3-induced myocarditis. PLoS One. 2011. 6(12):e28513. [Medline].
Yu Z, Huang Z, Sao C, et al. Bifidobacterium as an oral delivery carrier of interleukin-12 for the treatment of Coxsackie virus B3-induced myocarditis in the Balb/c mice. Int Immunopharmacol. 2012 Jan. 12(1):125-30. [Medline].
Blumental S, Reynders M, Willems A, et al. Enteroviral infection of a cardiac prosthetic device. Clin Infect Dis. 2011 Mar 15. 52(6):710-6. [Medline].
Abdel-Mageed WM, Bayoumi SA, Chen C, Vavricka CJ, Li L, Malik A, et al. Benzophenone C-glucosides and gallotannins from mango tree stem bark with broad-spectrum anti-viral activity. Bioorg Med Chem. 2014 Apr 1. 22 (7):2236-43. [Medline].
Stein EA, Pinkert S, Becher PM, Geisler A, Zeichhardt H, Klopfleisch R, et al. Combination of RNA interference and virus receptor trap exerts additive antiviral activity in coxsackievirus B3-induced myocarditis in mice. J Infect Dis. 2015 Feb 15. 211 (4):613-22. [Medline].
Wang SG, Kong LY, Li YH, Cheng XY, Su F, Tang S, et al. Structure-activity relationship of N-benzenesulfonyl matrinic acid derivatives as a novel class of coxsackievirus B3 inhibitors. Bioorg Med Chem Lett. 2015 Sep 1. 25 (17):3690-3. [Medline].
Axelsson C, Bondestam K, Frisk G, Bergstrom S, Diderholm H. Coxsackie B virus infections in women with miscarriage. J Med Virol. 1993 Apr. 39 (4):282-5. [Medline].
Hwang JH, Kim JW, Hwang JY, Lee KM, Shim HM, et al. Coxsackievirus B infection is highly related with missed abortion in Korea. Yonsei Med J. 2014 Nov. 55 (6):1562-7. [Medline].
Tang JW, Bendig JW, Ossuetta I. Vertical transmission of human echovirus 11 at the time of Bornholm disease in late pregnancy. Pediatr Infect Dis J. 2005 Jan. 24(1):88-9. [Medline].
Gaaloul I, Riabi S, Harrath R, Hunter T, Hamda KB, Ghzala AB, et al. Coxsackievirus B detection in cases of myocarditis, myopericarditis, pericarditis and dilated cardiomyopathy in hospitalized patients. Mol Med Rep. 2014 Dec. 10 (6):2811-8. [Medline].
Ronellenfitsch S, Tabatabai J, Bottcher S, Diedrich S, Frommhold D, et al. First report of a Chinese strain of coxsackie B3 virus infection in a newborn in Germany in 2011: a case report. J Med Case Rep. 2014 May 27. 8:164. [Medline].
McEvoy GK. Nonsteroidal Anti-inflammatory Agents. AHFS Drug information. Bethesda, Md: American Society of Health-System Pharmacists; 2000.
Ikeda RM, Kondracki SF, Drabkin PD, Birkhead GS, Morse DL. Pleurodynia among football players at a high school. An outbreak associated with coxsackievirus B1. JAMA. 1993 Nov 10. 270(18):2205-6. [Medline].
Kadurugamuwa JL, Shaheen E. Inactivation of human enterovirus 71 and coxsackie virus A16 and hand, foot, and mouth disease. Am J Infect Control. 2011 Nov. 39(9):788-9. [Medline].
Druce JD, Russell JS, Birch CJ, Vickery K, Harper RW, Smolich JJ. Cleaning and sterilization protocol for reused cardiac electrophysiology catheters inactivates hepatitis and coxsackie viruses. Infect Control Hosp Epidemiol. 2005 Aug. 26(8):720-5. [Medline].
Dussart P, Cartet G, Huguet P, et al. Outbreak of acute hemorrhagic conjunctivitis in French Guiana and West Indies caused by coxsackievirus A24 variant: phylogenetic analysis reveals Asian import. J Med Virol. 2005 Apr. 75(4):559-65. [Medline].
Huber S, Ramsingh AI. Coxsackievirus-induced pancreatitis. Viral Immunol. 2004. 17(3):358-69. [Medline].
Spotnitz MD, Lesch M. Idiopathic dilated cardiomyopathy as a late complication of healed viral (Coxsackie B virus) myocarditis: historical analysis, review of the literature, and a postulated unifying hypothesis. Prog Cardiovasc Dis. 2006 Jul-Aug. 49(1):42-57. [Medline].
Ornoy A, Tenenbaum A. Pregnancy outcome following infections by coxsackie, echo, measles, mumps, hepatitis, polio and encephalitis viruses. Reprod Toxicol. 2006 May. 21(4):446-57. [Medline].
Branch WT Jr, McNeil BJ. Analysis of the differential diagnosis and assessment of pleuritic chest pain in young adults. Am J Med. 1983 Oct. 75(4):671-9. [Medline].
Dagan R, Jenista JA, Prather SL, Powell KR, Menegus MA. Viremia in hospitalized children with enterovirus infections. J Pediatr. 1985 Mar. 106(3):397-401. [Medline].
Fraser RG, Pare JA. Coxsackievirus respiratory infection. Diag Dis Chest. 1978. 2:834-35.
Gaaloul I, Riabi S, Harrath R, Evans M, Salem NH, Mlayeh S. Sudden unexpected death related to enterovirus myocarditis: histopathology, immunohistochemistry and molecular pathology diagnosis at post-mortem. BMC Infect Dis. 2012. 12:212. [Medline].
Gomez Rodriguez N, Ibanez Ruan J, Gonzalez Rodriguez M. [Coxsackie virus infection associated with myositis and polyarthritis]. An Med Interna. 2008 Feb. 25(2):90-2. [Medline].
Grattagliano I, Portincasa P, Mastronardi M, Palmieri VO, Palasciano G. Esomeprazole-induced central fever with severe myalgia. Ann Pharmacother. 2005 Apr. 39(4):757-60. [Medline].
Lau RC. Coxsackie B virus infections in New Zealand patients with cardiac and non-cardiac diseases. J Med Virol. 1983. 11(2):131-7. [Medline].
Mintz L, Drew WL. Relation of culture site to the recovery of nonpolio enteroviruses. Am J Clin Pathol. 1980 Sep. 74(3):324-6. [Medline].
Murray BJ. Complications following coxsackievirus B infection. Am Fam Physician. 1988 Nov. 38(5):115-8. [Medline].
Pichichero ME, McLinn S, Rotbart HA, Menegus MA, Cascino M, Reidenberg BE. Clinical and economic impact of enterovirus illness in private pediatric practice. Pediatrics. 1998 Nov. 102(5):1126-34. [Medline].
Roth B, Enders M, Arents A, Pfitzner A, Terletskaia-Ladwig E. Epidemiologic aspects and laboratory features of enterovirus infections in Western Germany, 2000-2005. J Med Virol. 2007 Jul. 79(7):956-62. [Medline].
Storch GA. Essentials of Diagnostic Virology. New York, NY: Churchill Livingstone; 2000.
Swanink CM, Veenstra L, Poort YA, Kaan JA, Galama JM. Coxsackievirus B1-based antibody-capture enzyme-linked immunosorbent assay for detection of immunoglobulin G (IgG), IgM, and IgA with broad specificity for enteroviruses. J Clin Microbiol. 1993 Dec. 31(12):3240-6. [Medline]. [Full Text].
Tagarakis GI, Georgios TI, Karangelis D, Dimos K, Tsolaki F, Fani T. Bornholm disease--a pediatric clinical entity that can alert a thoracic surgeon. J Paediatr Child Health. 2011 Apr. 47(4):242. [Medline].
Wilson PM, Kusumakar V, McCartney RA, Bell EJ. Features of Coxsackie B virus (CBV) infection in children with prolonged physical and psychological morbidity. J Psychosom Res. 1989. 33(1):29-36. [Medline].