- Author: Irina Petrache, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Coxsackie B virus infection can be diagnosed by isolation of the virus in cell culture, detection of virus RNA via polymerase chain reaction (PCR) or serologic evaluation of viral antibodies.
- Viral cultures
- Primary monkey kidney cells or embryonic lung fibroblasts are the standard cells used for isolation and identification of coxsackievirus B. The addition of Buffalo green monkey kidney cells may increase the sensitivity of this method. Viral growth occurs in 1-4 days, causing a cytopathic effect on the host cells, resulting in rounded, refractile cells that eventually lyse. The cultures may be performed from various clinical specimens, dictated by the presence of clinical symptoms.
- Throat viral cultures are more sensitive than urine viral cultures and confirm 33% of the enteroviral infections studied. Throat culture findings were positive for coxsackievirus B in 45% of the patients presenting with pleurodynia. Blood cultures are useful in children younger than 3 months. Stool cultures have a higher yield than rectal swabs. Having multiple culture specimens may also increase the yield of virus recovery in culture.
- A positive enteroviral culture result must be interpreted in light of the clinical context and the history of polio immunization. After vaccination with the live attenuated oral polio vaccine, viral culture results from both throat and stool specimens may remain positive for enteroviruses for several months. Similarly, patients with asymptomatic infections may shed the virus for months after they acquire the infection.
- Cerebrospinal fluid (CSF) viral cultures have limited clinical utility in the management of enteroviral meningitis due to poor sensitivity (65-75%), high cost, and long turnaround time.
- Fluorescent staining and neutralization assays: Using specific antibodies, these tests are used to further confirm and delineate the type of enterovirus isolated from cell culture.
- Molecular diagnosis
- Molecular methods may soon replace viral culture and neutralization assays used to isolate and type enteroviruses. Viral culture and neutralization assays are reliable but time-consuming and costly methods.
- Reverse transcriptase PCR (RT-PCR) is now an established technique for the detection of viral nucleic acids, especially from specimens with a low viral load that may be associated with false-negative cell culture results. In the CSF, RT-PCR has better sensitivity than viral culture. In children, RT-PCR for throat specimens was also more sensitive than viral culture. Another advantage is the rapid turnaround time, which has resulted to improved health care costs, especially in the management of enteroviral meningitis.[7, 8]
- Commercial diagnostic RT-PCR kits are available for the identification of coxsackievirus B RNA.
- One disadvantage of RT-PCR is that the virus serotype cannot be identified. Additional restriction fragment length polymorphism (RFLP) assays may provide a simple strategy to identify the virus subtype.
- Reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay is a rapid, in vitro technique based on viral RNA amplification, targeting highly conserved regions in 5’ URT gene. In one study on 150 CSF and stool samples, the results were compared with those from RT-PCR. RT-LAMP assay showed high sensitivity and specificity in isolating and typing coxsackieviruses.
- Serologic studies for viral antigen detection: Specific antibodies against enteroviral groups and serotypes are commercially available, but their application has thus far been limited to fluorescent staining and detection of viral antigens in cell cultures, rather than clinical specimens.
- Enzyme-linked immunosorbent assay (ELISA) is more sensitive than the neutralization test and can be used as a screening tool, followed by the neutralization test for confirmation.
- ELISA using an enteroviruses group–specific monoclonal antibody may detect early immunoglobulin M (IgM) antibody secreted during coxsackievirus B infection. The test is more sensitive than the neutralization tests and can be used as a screening tool, followed by the neutralization test. The specificity is not extremely high because the antibodies cross-react with other enteroviruses such as hepatitis A virus.[11, 12]
- The neutralization assay measures the ability of the serum to antagonize the viral infectivity in cell culture. The cytopathic effect-based neutralization test (Nt-CPE) and the plaques reduction neutralization test (PRNT) are the most common methods for quantifying the neutralizing antibody titers.[13, 14] Although the tests are expensive and laborious, a more specific finding of a positive ELISA result followed by a negative neutralization test result usually signifies an enteroviral infection other than that caused by coxsackievirus B. An efficient neutralization test based on the enzyme-linked immunospot assay (Nt-ELISPOT) has shortened the testing period from 7 days to approximately 20 hours, with good correlation (r2=0.9462) between the Nt-ELISPOT and the Nt-CPE assays. This modified Nt-ELISPOT would allow for faster specimen processing in coxsackievirus B vaccine trails, which require testing of a large number of serum specimens.
- Complement fixation test: This test is another laborious method of measuring antiviral antibodies used to diagnose coxsackievirus B infection.
- Other tests and findings
- Serum creatine kinase is usually elevated because of muscle necrosis.
- The white cell count ranges from mild leukopenia to mild leukocytosis.
- Although seldom performed for the diagnosis of pleurodynia per se, tissue diagnosis can be made by direct detection of the viral antigen or by isolation of RNA virus-specific sequences.
- Depending on the clinical presentation and suspicion for serositis caused by systemic lupus erythematosus, an antinuclear antibody test can be performed.
- A chest radiograph is usually obtained to exclude other causes of chest pain. In pleurodynia, the findings on chest radiography can be normal, or the radiograph may show a small amount of ipsilateral pleural effusion or adjacent atelectasis from splinting.
- The atelectasis can be linear or in the form of bibasilar consolidation.
- Infrequently, the coxsackievirus B infection causes pneumonia, with a radiographic pattern of fine perihilar opacities.
Necrosis of the striated intercostal muscles is visible. Rarely, adjacent pleural inflammation results in a small exudative pleural effusion.
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].