eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Enteroviral Infections: Follow-up

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

Follow-up

Further Inpatient Care

  • The course of enterovirus infection widely varies; therefore, each case must be individually handled. Neonatal meningitis and septic cases require careful observation for CNS changes. Cultures must be carefully obtained and monitored.
  • Patients with paralytic poliovirus should be admitted to the ICU. Ventilatory support should be arranged as needed.
  • Bulbar poliomyelitis involves cranial nerve weakness, respiratory problems, and circulatory problems. These patients should be carefully handled and should be liberally offered ventilatory support.
  • Patients with poliomyelitis who have bladder paresis may require urinary catheterization. Constipation, another effect of poliomyelitis, can be treated with stool softeners and cathartics as needed.

Further Outpatient Care

  • Pediatric patients with nonpolio infections can be discharged if they are not septic and if they do not have symptoms of meningitis. Arrange for follow-up with pediatrician in 1-2 days.

Inpatient & Outpatient Medications

  • Outpatient medications consist of antipyretics and analgesics to be used as needed.

Transfer

  • No specific indications for transfer are recognized in patients with enteroviral infections.
    • Transfer may be needed for lack of intensive care setting, in such cases as neonatal setting or poliomyelitis.
    • As is the general rule of transfer, the main concern is to ensure airway patency prior to travel. If any question of airway stability is present, the physician should intubate the patient prior to transfer.

Deterrence/Prevention

  • All children should receive vaccination for poliovirus. Two forms of the vaccine are available, and both are equally effective in creating immunity.
    • The inactivated poliovirus vaccine, developed by Salk, offers immunity without the risk of vaccine-associated paralytic polio (VAPP). The inactivated poliovirus vaccine is more invasive, which means the child receives more injections.
    • The OPV, developed by Sabin, consists of live-attenuated poliovirus. Oral polio vaccine (OPV) creates local community and herd immunity through viral shedding by the intestinal tract and is less invasive.
    • As of June 1999, recommendations by the Advisory Committee on Immunization Practices (ACIP) suggest inactivated polio vaccine administration. Because of decreased worldwide incidence of polio and likelihood of imported cases, a regimen consisting solely of inactivated polio vaccine has replaced the former combined inactivated polio vaccine and OPV regimen. This change reflects an effort to decrease the cases of vaccine-associated polio. All children should receive the inactivated polio vaccine at age 2 months, age 4 months, age 6-18 months, and age 4-6 years.
  • Guidelines for increasing immunization coverage have been established.9

Complications

  • Both coxsackievirus and enterovirus have been associated with the development of Guillain-Barré syndrome.
  • Coxsackieviruses have been hypothesized to play a role in the development of insulin-dependent diabetes mellitus. Rodent models have demonstrated enteroviral destruction of pancreatic beta-islet cells, but no definitive link has been established. In a 1995 study in Finland, Hyoty et al demonstrated elevated blood levels of enteroviral immunoglobulins in the mothers of children with insulin-dependent diabetes mellitus as compared with pregnant mothers of nondiabetic children.10
  • Several studies have investigated a possible link between enteroviral infections and increased risk of myocardial infarction, but no definite conclusions have been proven.

Prognosis

  • The prognosis for nonpolio enteroviral infections is excellent. Bad outcomes are specifically related to cases of newborn infections and older children with myocarditis and encephalitis.
  • In most cases of polio, patients have some return of muscle function. Prognosis of final ability is determined 6 months or longer following the infection.

Patient Education

  • Frequent handwashing and good hygiene can reduce the risk of acquiring an enteroviral infection.

Miscellaneous

Medicolegal Pitfalls

  • Although diagnosing enteroviral infections is quite useful, it does not exclude the possibility of a concomitant bacterial infection.

Special Concerns

  • Pregnant females should theoretically not receive polio vaccination, although no bad outcomes have been documented. If vaccine is required for necessary protection, both inactivated polio vaccine and oral polio vaccine (OPV) are safe. Also, breastfeeding can continue without concerns.
  • OPV vaccine is contraindicated in immunocompromised patients and household members of these patients because it contains live-attenuated virus. The Sabin vaccine was developed through long-term passage of virus, but genetic analysis shows that a single RNA base change in the transcription initiation site can restore near–wild-type replication kinetics.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Michelle Mowad, MD, to the original writing and development of this article.



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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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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