eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Enteroviral Infections: Differential Diagnoses & Workup

Author: Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Contributor Information and Disclosures

Updated: Jun 5, 2009

Differential Diagnoses

Diphtheria
Pharyngitis
Herpes Simplex Virus Infection
Pneumococcal Bacteremia
Meningitis, Aseptic
Pneumonia
Meningitis, Bacterial
Rabies
Meningococcal Infections
Tetanus
Pericarditis, Bacterial
Toxicity, Lead
Pericarditis, Constrictive
Pericarditis, Viral

Other Problems to Be Considered

Guillain-Barré syndrome
Viral encephalitis
Tick-borne paralysis

Workup

Laboratory Studies

  • The diagnosis of enteroviral infection is most often based on the clinician's assessment of the patient in conjunction with seasonal outbreaks, known exposure risks, geographic locations, and age groups. Ancillary laboratory test results aid the physician in supportive care of the patient and eliminate other potentially harmful and treatable bacterial illnesses. Diagnostic testing plays a role in enteroviral infections. As newer methods have demonstrated increased sensitivities, determining viral etiologies of aseptic meningitis and neonatal sepsis has resulted in improved patient care.
  • Cell culture, serology, and polymerase chain reaction (PCR) laboratory testing can diagnostically isolate enteroviral infections. Enteroviruses are found in stool, the pharynx, blood, and cerebral spinal fluid (CSF). Blood cultures and serology are of questionable use because the viral levels may be undetectable by the time symptoms have appeared. Pharyngeal viral levels remain present from 2 days to 2 weeks after the infection. Stool isolation of enteroviruses is not specific to acute infections because viral stool shedding persists for as long as 3 months after the infection.
  • Historically, the criterion standard of isolation has been cell cultures; however, clinical evidence is proving PCR tests to be both more sensitive and more efficient. Tissue cultures take approximately 3-8 days to grow the enterovirus, and the identification of the subtype requires even more time. Overall, low cell culture sensitivity rates of 65-75% have been repeatedly demonstrated in enteroviral meningitis.
  • Another method, serologic testing, uses multiple titers to identify a pattern of rising antibody levels over a 2-week to 4-week period. A single level of enteroviral antibodies can be present in a healthy patient; therefore, monitoring the serology to identify a 4-fold increase in levels is needed. Identifying the specific subtype and monitoring the antibody levels is labor intensive. Furthermore, waiting for periods of 2-4 weeks for tissue results is not useful in improving patient care.
  • In contrast, the reverse transcriptase PCR testing is designed to detect a common genetic area in the enteroviral subtypes. The results are available in 24 hours, making detection more sensitive (95%), more specific (97%), and more time efficient. Both Chonmaitree et al in 1982 and Singer et al in 1980 demonstrated the positive outcomes of viral detection in aseptic meningitis, yielding shortened hospital stay and antibiotic course.6,7
    • Recent studies have demonstrated the efficacy and increased sensitivity of using the PCR technique to isolate CSF enterovirus. 
    • PCR testing may also play a pivotal role in identifying epidemiological outbreaks of infections.
    • In 1997, Ahmed et al demonstrated 100% sensitivity and 90% specificity using PCR CSF assays in conjunction with viral cultures to detect enteroviral meningitis in infants younger than 3 months.8
  • Poliomyelitis can be isolated from stool, nasopharyngeal mucosa, and CSF. Stool specimens have the greatest yield for polio. Antibody serology titers demonstrate a 4-fold rise and must be acquired at early onset of illness. If positive, samples must be sent to the CDC.
  • Ancillary laboratory tests may also be helpful in treating patients. CBC count results vary, demonstrating a WBC count within the reference range or demonstrating a mild elevation of WBCs with neutrophilia or leukocytosis.
  • A basic chemistry panel is only useful in patients with extreme lethargy or dehydration and is used to eliminate possible diagnosis of electrolyte imbalances.
  • Erythrocyte sedimentation rate is a nonspecific test, and the results should be elevated in any inflammatory process, including enteroviral infections.
  • Urinalysis is a part of the sepsis workup in neonates and young children to eliminate bacterial infections. Also, blood and urine cultures should be obtained.
  • Measure cardiac enzymes.

Imaging Studies

  • Chest radiographs should be obtained as part of the neonatal sepsis workup and in cases of pleurodynia. Radiographic findings are normal in patients with pleurodynia.
  • Obtain echocardiographs.

Other Tests

  • Obtain ECG in suspected cases of pericarditis. The ECG results can be normal, can be nonspecific, or can have changes common to all causes of pericarditis.

Procedures

  • Lumbar puncture is the most important test in meningitis. Send CSF for cell count with differential, protein, glucose, Gram stain, and bacterial cultures. Send extra fluid for PCR testing and viral cell cultures.
    • CSF fluid demonstrates aseptic meningitis in patients with polio and nonpolio virus.
    • Often, the WBC count is less than 500/mL, with an initial 2 days of polymorphonuclear cell predominance that is replaced by mononuclear cells. The protein level can be within the reference range or mildly elevated (80-100 mg/100 mL). The glucose level is within the reference range.

More on Enteroviral Infections

Overview: Enteroviral Infections
Differential Diagnoses & Workup: Enteroviral Infections
Treatment & Medication: Enteroviral Infections
Follow-up: Enteroviral Infections
Multimedia: Enteroviral Infections
References
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References

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Further Reading

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Keywords

enteroviral infections, enterovirus, poliovirus, echovirus, coxsackie virus, coxsackievirus, oral polio vaccine, OPV, inactivated polio vaccine, IPV, hand-foot-and-mouth disease, HFM, herpangina, myocarditis, pleurodynia, aseptic meningitis, neonatal sepsis, viremia, biphasic prodromal illness, hepatic necrosis, viral exanthems, vaccine-associated paralytic polio, VAPP, Sabin vaccine, monovalent oral polio vaccine, mOPV, global encephalitis, rhombencephalitis, myoclonus, acute hemorrhagic conjunctivitis, myalgia, orchitis, epididymitis, meningococcemia, neurogenic pulmonary edema, pleurodynia, Bornholm disease, devil’s grippe, bulbar poliomyelitis, auscultatory fiction rub, Hamman crunch, coryza, X-linked agammaglobulinemia, Guillain-Barré syndrome, treatment, diagnosis

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Contributor Information and Disclosures

Author

Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MB, BCh, PhD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Mobeen H Rathore, MD, CPE, FAAP, FIDSA, Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)
Mobeen H Rathore, MD, CPE, FAAP, FIDSA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, European Society for Paediatric Infectious Diseases, Florida Medical Association, Florida Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America, Society for Pediatric Research, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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