eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Enteroviral Infections: Treatment & Medication
Updated: Jun 5, 2009
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Treatment
Medical Care
Unfortunately, no specific antiviral medication or treatment is available for an enteroviral infection. The best care is provided through supportive measures. Fluid hydration and antipyretics are the mainstays of care for a viral syndrome.
- In patients with severe illness, if a bacterial infection is suspected, antibiotics are administered at the physician's discretion. Test results, such as polymerase chain reaction (PCR) test results from cerebrospinal fluid (CSF) samples, require 24 hours to return, and a positive result does not necessarily eliminate a bacterial infection. Thus, the use of cultures is important.
- Corticosteroids have been proposed to have a beneficial effect on myocarditis, but no significant improvement has been demonstrated. Furthermore, because of deleterious side effects, steroids are not recommended for treatment.
- Intravenous immune globulin (IVIG) has been suggested to be beneficial in the outcome of myocarditis because of immunoglobulin G (IgG) and T-cell modulation. Other indications include possible efficacy in infections in newborns and patients with agammaglobulinemia.
- Although not approved by the US Food and Drug Administration, (FDA), pleconaril may play a role in the treatment plan in the future.
- The best medical care involves continued efforts for worldwide poliovirus vaccination.
Consultations
- If poliomyelitis is suspected, consultation with a neurologist and a physical medicine specialist is helpful. Furthermore, CDC notification is required because they are responsible for virus surveillance. The CDC investigates cases of suspected polio and helps to identify the etiology of the case.
- For nonpoliovirus enteroviruses, no consultations are specifically required, but the physician should address individual clinical situations.
Diet
- Patients can continue with a normal diet.
- Soft foods and liquids are appeasing to children with herpangina.
Activity
- As with any illness, children should avoid vigorous activity that may contribute to fluid losses and exhaustion.
Medication
Antiviral therapy is not currently a component in the standard of care for enteroviral infection. Studies with investigational antiviral agents are currently ongoing. Current treatment remains purely supportive.
Antipyretic and analgesic agents
These agents are used to treat fever, myalgia, and headache associated with enterovirus.
Acetaminophen (Tylenol, FeverAll)
Reduces fever by directly acting on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in people with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; combined use with OTC products that contain acetaminophen may result in cumulative doses that exceed recommended maximum dose
Ibuprofen (Motrin, Advil)
One of the few NSAIDs indicated for reduction of fever.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Immunoglobulins
This agent is a purified preparation of gamma globulin derived from large pools of human plasma and is composed of 4 subclasses of antibodies, approximating the distribution of human serum.
Immune globulin, intravenous (Carimune NF, Gammagard, Polygam S/D)
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies. Down-regulates proinflammatory cytokines, including INF-gamma. Blocks Fc receptors on macrophages. Suppresses inducer T and B cells and augments suppressor T cells. Blocks complement cascade and promotes remyelination. May increase CSF IgG (10%).
Adult
2 g/kg IV as a single infusion over 12 h; alternatively, 2 g/kg IV as a single dose infused over 4 d (ie, over 96 h); must gradually increase rate of infusion to avoid infusion-related toxicity
Pediatric
750 mg/kg IV as a single infusion over 12 h; alternatively, 750 mg/kg IV as a single dose infused over 4 d (ie, over 96 h); must gradually increase rate of infusion to avoid infusion-related toxicity
Globulin preparation may interfere with immune response to live virus vaccine (MMR) and reduce efficacy (do not administer within 3 mo of vaccine)
Documented hypersensitivity; IgA deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Check serum IgA before IVIG administration (obtain a low IgA product if necessary); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-30 d postinfusion); increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; laboratory result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia
Antiviral agents
One antiviral medication (pleconaril) has shown promise in treating enteroviral infections, but its use has so far been largely restricted to experimental protocols. Its release has been repeatedly delayed, and it is still not yet licensed in the United States.
Pleconaril (Picovir)
Investigational in the United States. Low-molecular weight capsid-inhibitor fits into the hydrophobic pocket of the VP1 capsid protein and interferes with viral attachment and uncoating. Has shown efficacy against enterovirus species.
Several clinical trials in adults have shown good drug tolerability with low adverse effects. Drug distribution shows good penetration into the liver, CNS, and nasal mucosa. Efficacy demonstrated in terms of symptom scores, nasal mucus production, and length of illness in studies in which administration of the drug precedes or coincides with experimental enterococcus inoculation. Bioavailability increases more than 2-fold when administered with a fatty meal compared with administration in a fasting state. Treatment of subjects presenting with a "common cold" reduced the disease duration by about 1 d.
Several case reports document successful treatment of severe or life-threatening infections. Data in children is extremely limited. Studies are underway. Contact Schering-Plough for information regarding experimental protocols or compassionate need.
Adult
200 mg PO bid for 5-7 d; administer with a fatty meal
Pediatric
1-5 mg/kg/dose PO qd/tid; dose and administration frequency varies depending on experimental protocol being followed
Pediatric doses are typically higher per kg, perhaps due to a greater volume of distribution in infants and neonates and/or lower bioavailability
Mild CYP 3A4 isoenzyme inducer; reduces PO contraceptive serum concentrations, and users report a significantly higher rate of menstrual irregularities (69% in patients who use PO contraceptives and receive 400 mg bid vs about 25% in patients who do not use PO contraceptives and receive any pleconaril dose or patients who use PO contraceptives and do not receive pleconaril), long-term use (ie, >1 mo) may increase the rate of pregnancy because of these irregularities (suggest alternate birth control method); may increase theophylline serum concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Experimental drug; although current data show a generally good safety profile, administration is still limited to compassionate use in severe, life-threatening enterovirus infections; caution in renal or hepatic impairment due to limited data
More on Enteroviral Infections |
| Overview: Enteroviral Infections |
| Differential Diagnoses & Workup: Enteroviral Infections |
 Treatment & Medication: Enteroviral Infections |
| Follow-up: Enteroviral Infections |
| Multimedia: Enteroviral Infections |
| References |
| « Previous Page | Next Page » |
References
Pichichero ME, McLinn S, Rotbart HA, et al. Clinical and economic impact of enterovirus illness in private pediatric practice. Pediatrics. Nov 1998;102(5):1126-34. [Medline]. [Full Text].
Picornaviridae Study Group. New and Re-classified TypesGenus Parechovirus, species Human parechovirus. Available at http://www.picornastudygroup.com/types/parechovirus/hpev.htm. Accessed 3/14/09.
CDC. Enterovirus surveillance--United States, 1997-1999. MMWR Morb Mortal Wkly Rep. Oct 13 2000;49(40):913-6. [Medline].
Global Polio Eradication Initiative. Wild Poliovirus Weekly Update. Global Polio Eradication. Available at http://www.polioeradication.org/casecount.asp. Accessed 3/14/09.
Ooi MH, Wong SC, Mohan A, Podin Y, Perera D, Clear D, et al. Identification and validation of clinical predictors for the risk of neurological involvement in children with hand, foot, and mouth disease in Sarawak. BMC Infect Dis. Jan 19 2009;9:3. [Medline].
Chonmaitree T, Menegus MA, Powell KR. The clinical relevance of 'CSF viral culture'. A two-year experience with aseptic meningitis in Rochester, NY. JAMA. Apr 2 1982;247(13):1843-7. [Medline].
Singer JI, Maur PR, Riley JP, Smith PB. Management of central nervous system infections during an epidemic of enteroviral aseptic meningitis. J Pediatr. Mar 1980;96(3 Pt 2):559-63. [Medline].
Ahmed A, Brito F, Goto C, et al. Clinical utility of the polymerase chain reaction for diagnosis of enteroviral meningitis in infancy. J Pediatr. Sep 1997;131(3):393-7. [Medline].
Wood DL. Increasing immunization coverage. American Academy of Pediatrics Committee on Community Health Services. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine. Pediatrics. Oct 2003;112(4):993-6. [Medline].
Hyoty H, Hiltunen M, Knip M, et al. A prospective study of the role of coxsackie B and other enterovirus infections in the pathogenesis of IDDM. Childhood Diabetes in Finland (DiMe) Study Group. Diabetes. Jun 1995;44(6):652-7. [Medline].
Abzug MJ, Keyserling HL, Lee ML, et al. Neonatal enterovirus infection: virology, serology, and effects of intravenous immune globulin. Clin Infect Dis. May 1995;20(5):1201-6. [Medline].
Abzug MJ, Levin MJ, Rotbart HA. Profile of enterovirus disease in the first two weeks of life. Pediatr Infect Dis J. Oct 1993;12(10):820-4. [Medline].
Andrus JK, Strebel PM, de Quadros CA, Olive JM. Risk of vaccine-associated paralytic poliomyelitis in Latin America, 1989-91. Bull World Health Organ. 1995;73(1):33-40. [Medline].
Ballow M. Mechanisms of action of intravenous immune serum globulin in autoimmune and inflammatory diseases. J Allergy Clin Immunol. Aug 1997;100(2):151-7. [Medline].
Gaspar BG, Kinnon C. Humoral Immunodeficiency: X-linked agammaglobulinemia. Immunol Allergy Clin North Am. 2001;21(1).
Huang CC, Liu CC, Chang YC, et al. Neurologic complications in children with enterovirus 71 infection. N Engl J Med. Sep 23 1999;341(13):936-42. [Medline].
Jiang P, Faase JA, Toyoda H, et al. Evidence for emergence of diverse polioviruses from C-cluster coxsackie A viruses and implications for global poliovirus eradication. Proc Natl Acad Sci U S A. May 29 2007;104(22):9457-62. [Medline]. [Full Text].
Kohler KA, Banerjee K, Gary Hlady W, Andrus JK, Sutter RW. Vaccine-associated paralytic poliomyelitis in India during 1999: decreased risk despite massive use of oral polio vaccine. Bull World Health Organ. 2002;80(3):210-6. [Medline].
Morag A, Ogra P. Enteroviruses. In: Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000.
Norris CM, Danis PG, Gardner TD. Aseptic meningitis in the newborn and young infant. Am Fam Physician. May 15 1999;59(10):2761-70. [Medline].
Prager P, Nolan M, Andrews IP, Williams GD. Neurogenic pulmonary edema in enterovirus 71 encephalitis is not uniformly fatal but causes severe morbidity in survivors. Pediatr Crit Care Med. Jul 2003;4(3):377-81. [Medline].
Prevots DR, Burr RK, Sutter RW, Murphy TV,. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. May 9 2000;49(RR-5):1-22; quiz CE1-7. [Medline]. [Full Text].
Roivainen M. Enteroviruses and myocardial infarction. Am Heart J. Nov 1999;138(5 Pt 2):S479-83. [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. Oct 1994;32(10):2590-2. [Medline]. [Full Text].
Shechet RJ, Tanenbaum B. Preventing unnecessary hypospadias repair. Am Fam Physician. Nov 1 1999;60(7):1933. [Medline].
WHO. Progress towards interruption of wild poliovirus transmission in 2005. Wkly Epidemiol Rec. Apr 28 2006;81(17):165-72. [Medline]. [Full Text].
Wilfert CM, Lehrman SN, Katz SL. Enteroviruses and meningitis. Pediatr Infect Dis. Jul-Aug 1983;2(4):333-41. [Medline].
Yang TT, Huang LM, Lu CY, et al. Clinical features and factors of unfavorable outcomes for non-polio enterovirus infection of the central nervous system in northern Taiwan, 1994-2003. J Microbiol Immunol Infect. Dec 2005;38(6):417-24. [Medline]. [Full Text].
Zaoutis T, Klein JD. Enterovirus infections. Pediatr Rev. Jun 1998;19(6):183-91. [Medline].
Further Reading
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
