Laboratory Studies

Diagnosis of enterovirus infections is often clinical. Laboratory diagnosis can be achieved with serological tests, viral isolation by cell culture, and polymerase chain reaction (PCR).

Serology

The microneutralization test is the most widely used method for detecting antibodies to enteroviruses. Serological examination reveals a 4-fold increase in antibodies to enteroviruses between the acute and convalescent phases of illness.^[62]This diagnostic modality is infrequently used since it is serotype-specific, relatively insensitive, poorly standardized, labor intensive, and too slow for clinical purposes.

Viral isolation

The virus can be isolated from CSF, blood, or feces, depending on the site affected, and the yield is increased if multiple sites are sampled. Enterovirus produces a characteristic cytopathic effect in cultured cells. Poliovirus is easily cultured from stool and nasopharyngeal secretions, but isolation from the CSF is more difficult. The cytopathic effect is confirmed by indirect immunofluorescence using a broadly specific monoclonal antibody. The sensitivity of viral culture ranges from 60%-75%.^[63]

Polymerase chain reaction

This rapid test is highly sensitive and specific for detecting enteroviral RNA in CSF specimens, with a sensitivity of 100% and specificity of 97%.^{[64, 65]}PCR provides rapid results and is the best diagnostic test for use in CSF but is limited by availability in some areas and cost in underdeveloped regions.^[66]

In 2008, a multiplex real-time PCR (RT-PCR) assay was developed for simultaneous detection, identification, and quantification of enterovirus 70 and a coxsackievirus A24 variant. The novel technique is used as a rapid diagnostic method to evaluate for enterovirus-related AHC.^[67]

Cardiac enzyme levels

Cardiac enzyme levels may be elevated in persons with myopericarditis, indicating myocardial damage.

CSF analysis

The CSF profile in patients with aseptic meningitis usually reveals a mildly elevated white blood cell count, and the differential invariably shifts to a predominance of lymphocytes during the initial 1-2 days of illness. Glucose levels are normal or mildly decreased,^[68]while the protein level is normal or slightly increased.

Imaging Studies

Chest radiography: In patients with myopericarditis, chest radiography may reveal cardiomegaly secondary to pericardial effusion or cardiac dilation. In pleurodynia, chest radiographic findings are normal.

Echocardiography: Transient wall motion abnormalities may be detectable in mild cases. Severe cases may demonstrate acute ventricular dilation and reduced ejection fraction.

Other Tests

ECG: Nonspecific ST-T changes may be observed in persons with myopericarditis. Severe disease may cause Q waves, ventricular tachyarrhythmias, and heart block. ECG findings may demonstrate evolution through several stages of myopericarditis, as follows:

Stage I - Diffuse ST elevation with PR depression
Stage II - Normalization of ST and PR segments
Stage III - Deep symmetric inversion of T waves
Stage IV - May revert to normal or permanent T-wave inversions

Electroencephalography: This test may be useful for evaluating the extent and severity of illness in patients with encephalitis.

Ophthalmic slit-lamp examination: In persons with AHC, corneal erosions may be visualized using a fluorescein stain. Enterovirus 70 and coxsackievirus A24 can often be recovered from conjunctival swabs during the first 3 days of infection.

Histologic Findings

Histopathologic findings in most enterovirus infections are usually nonspecific, consisting primarily of lymphocytic infiltrates and cellular destruction.

Histologic findings in patients with polio have been well studied. Evidence of infection is pronounced in the spinal cord, medulla, pons, and mid brain. Neuronal destruction is observed, along with an inflammatory infiltrate composed of lymphocytes, macrophages, and polymorphonuclear leukocytes.

Treatment & Management

Rashid M, Khan MN, Jalbani N. Detection of Human Adenovirus, Rotavirus, and Enterovirus in Tap Water and Their Association with the Overall Quality of Water in Karachi, Pakistan. Food Environ Virol. 2021 Mar. 13 (1):44-52. [Medline].
Kogon A, Spigland I, Frothingham TE, Elveback L, Williams C, Hall CE. The virus watch program: a continuing surveillance of viral infections in metropolitan New York families. VII. Observations on viral excretion, seroimmunity, intrafamilial spread and illness association in coxsackie and echovirus infections. Am J Epidemiol. 1969 Jan. 89(1):51-61. [Medline].
Koh WM, Bogich T, Siegel K, Jin J, Chong EY, Tan CY, et al. The Epidemiology of Hand, Foot and Mouth Disease in Asia: A Systematic Review and Analysis. Pediatr Infect Dis J. 2016 Jun 3. [Medline].
Smith WG. Coxsackie B myopericarditis in adults. Am Heart J. 1970 Jul. 80(1):34-46. [Medline].
Koontz CH, Ray CG. The role of Coxsackie group B virus infections in sporadic myopericarditis. Am Heart J. 1971 Dec. 82(6):750-8. [Medline].
Kono R, Uchida Y. Acute hemorrhagic conjunctivitis. Ophthalmol Dig. 1977. 39:14.
Rorabaugh ML, Berlin LE, Heldrich F, et al. Aseptic meningitis in infants younger than 2 years of age: acute illness and neurologic complications. Pediatrics. 1993 Aug. 92(2):206-11. [Medline].
Modlin JF, Dagan R, Berlin LE, Virshup DM, Yolken RH, Menegus M. Focal encephalitis with enterovirus infections. Pediatrics. 1991 Oct. 88(4):841-5. [Medline].
Quartier P, Debre M, De Blic J, et al. Early and prolonged intravenous immunoglobulin replacement therapy in childhood agammaglobulinemia: a retrospective survey of 31 patients. J Pediatr. 1999 May. 134(5):589-96. [Medline].
Melnick JL. The discovery of the enteroviruses and the classification of poliovirus among them. Biologicals. 1993 Dec. 21(4):305-9. [Medline].
Oberste MS, Maher K, Kilpatrick DR, Flemister MR, Brown BA, Pallansch MA. Typing of human enteroviruses by partial sequencing of VP1. J Clin Microbiol. 1999 May. 37(5):1288-93. [Medline]. [Full Text].
Oberste MS, Maher K, Michele SM, Belliot G, Uddin M, Pallansch MA. Enteroviruses 76, 89, 90 and 91 represent a novel group within the species Human enterovirus A. J Gen Virol. 2005 Feb. 86:445-51. [Medline].
Oberste MS, Maher K, Nix WA, et al. Molecular identification of 13 new enterovirus types, EV79-88, EV97, and EV100-101, members of the species Human Enterovirus B. Virus Res. 2007 Sep. 128(1-2):34-42. [Medline].
Rueckert RR. Picornaviridae and their replication. Fields BN, Knipe DM, eds. Virology. 2nd ed. New York: Raven Press; 1990. 507.
Couch RB, Douglas RG Jr, Lindgren KM, Gerone PJ, Knight V. Airborne transmission of respiratory infection with coxsackievirus A type 21. Am J Epidemiol. 1970 Jan. 91(1):78-86. [Medline].
Onorato IM, Morens DM, Schonberger LB, Hatch MH, Kaminski RM, Turner JP. Acute hemorrhagic conjunctivitis caused by enterovirus type 70: an epidemic in American Samoa. Am J Trop Med Hyg. 1985 Sep. 34(5):984-91. [Medline].
Wolf JL, Rubin DH, Finberg R, et al. Intestinal M cells: a pathway for entry of reovirus into the host. Science. 1981 Apr 24. 212(4493):471-2. [Medline].
Horstmann DM, Mccollum RW. Poliomyelitis virus in human blood during the minor illness and the asymptomatic infection. Proc Soc Exp Biol Med. 1953 Mar. 82(3):434-7. [Medline].
Minor PD, John A, Ferguson M, Icenogle JP. Antigenic and molecular evolution of the vaccine strain of type 3 poliovirus during the period of excretion by a primary vaccinee. J Gen Virol. 1986 Apr. 67 ( Pt 4):693-706. [Medline].
Rose NR, Wolfgram LJ, Herskowitz A, Beisel KW. Postinfectious autoimmunity: two distinct phases of coxsackievirus B3-induced myocarditis. Ann N Y Acad Sci. 1986. 475:146-56. [Medline].
Ogra PL, Karzon DT. Formation and function of poliovirus antibody in different tissues. Prog Med Virol. 1971. 13:157.
Torfason EG, Reimer CB, Keyserling HL. Subclass restriction of human enterovirus antibodies. J Clin Microbiol. 1987 Aug. 25(8):1376-9. [Medline]. [Full Text].
Rager-Zisman B, Allison AC. The role of antibody and host cells in the resistance of mice against infection by coxsackie B-3 virus. J Gen Virol. 1973 Jun. 19(3):329-38. [Medline].
Centers for Disease Control and Prevention (CDC). Enterovirus surveillance--United States, 2002-2004. MMWR Morb Mortal Wkly Rep. 2006 Feb 17. 55(6):153-6. [Medline].
Centers for Disease Control and Prevention. Enterovirus surveillance--United States, 2000-2001. MMWR Morb Mortal Wkly Rep. 2002 Nov 22. 51(46):1047-9. [Medline].
Ikeda T, Mizuta K, Abiko C, Aoki Y, Itagaki T, Katsushima F, et al. Acute respiratory infections due to enterovirus 68 in Yamagata, Japan between 2005 and 2010. Microbiol Immunol. 2012 Feb. 56(2):139-43. [Medline].
Cortese MM, Kambhampati AK, Schuster JE, Alhinai Z, Nelson GR, Guzman Perez-Carrillo GJ, et al. A ten-year retrospective evaluation of acute flaccid myelitis at 5 pediatric centers in the United States, 2005-2014. PLoS One. 2020. 15 (2):e0228671. [Medline].
Elrick MJ, Pekosz A, Duggal P. Enterovirus D68 Molecular and Cellular Biology, and Pathogenesis. J Biol Chem. 2021 Jan 20. 100317. [Medline].
Biggs HM, Nix WA, Zhang J, Rogers S, Clara W, Jara JH, et al. Enterovirus D68 infection among hospitalized children with severe acute respiratory illness in El Salvador and Panama, 2012-2013. Influenza Other Respir Viruses. 2021 Mar. 15 (2):181-187. [Medline].
Xiang Z, Xie Z, Liu L, Ren L, Xiao Y, Paranhos-Baccalà G, et al. Genetic divergence of enterovirus D68 in China and the United States. Sci Rep. 2016 Jun 9. 6:27800. [Medline].
Enterovirus D68. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001. Accessed: September 11, 2014.
Foster CB, Coelho R, Brown PM, Wadhwa A, Dossul A, Gonzalez BE, et al. A comparison of hospitalized children with enterovirus D68 to those with rhinovirus. Pediatr Pulmonol. 2017 Jan 30. [Medline].
Lipson SM, Walderman R, Costello P. Sensitivity of rhabdomyosarcoma and guinea pig embryo cell cultures to field isolates of difficult-to-cultivate group A coxsackieviruses. J Clin Microbiol. 1986. 26:1298.
World Health Organization - Regional Office for Eastern Mediterranean. AFP Surveillance, Polio Fax weekly bulletin. World Health Organization - Regional Office for Eastern Mediterranean. 9/7/2009.
Center for Disease Control and Prevention. Glopal Polio Erradication Program. CDC. July 2009.
Global Polio Eradication Initiative. Wild Poliovirus Weekly Update. Sept 8,2009. Available at http://www.polioeradication.org/casecount.asp.
Kim HJ, Kang B, Hwang S, Hong J, Kim K, Cheon DS. Epidemics of viral meningitis caused by echovirus 6 and 30 in Korea in 2008. Virol J. 2012 Feb 15. 9:38. [Medline]. [Full Text].
Bubba L, Broberg EK, Jasir A, Simmonds P, Harvala H, Enterovirus study collaborators. Circulation of non-polio enteroviruses in 24 EU and EEA countries between 2015 and 2017: a retrospective surveillance study. Lancet Infect Dis. 2020 Mar. 20 (3):350-361. [Medline].
Fairweather D, Frisancho-Kiss S, Njoku DB, Nyland JF, Kaya Z, Yusung SA. Complement receptor 1 and 2 deficiency increases coxsackievirus B3-induced myocarditis, dilated cardiomyopathy, and heart failure by increasing macrophages, IL-1beta, and immune complex deposition in the heart. J Immunol. 2006 Mar 15. 176(6):3516-24. [Medline].
Curnen EC, Shaw EW, Melnick JL. Disease resembling nonparalytic poliomyelitis associated with a virus pathogenic for infant mice. J Am Med Assoc. 1949 Nov 26. 141(13):894-901. [Medline].
Weller TH, Enders JF, Buckingham M, Finn JJ Jr. The etiology of epidemic pleurodynia: a study of two viruses isolated from a typical outbreak. J Immunol. 1950 Sep. 65(3):337-46. [Medline].
Warin JF, Davies JB, Sanders FK, Vizoso AD. Oxford epidemic of Bornholm disease, 1951. Br Med J. 1953 Jun 20. 1(4824):1345-51. [Medline].
Narula J, Khaw BA, Dec GW Jr, et al. Brief report: recognition of acute myocarditis masquerading as acute myocardial infarction. N Engl J Med. 1993 Jan 14. 328(2):100-4. [Medline].
Kono R. Apollo 11 disease or acute hemorrhagic conjunctivitis: a pandemic of a new enterovirus infection of the eyes. Am J Epidemiol. 1975 May. 101(5):383-90. [Medline].
Sklar VE, Patriarca PA, Onorato IM, et al. Clinical findings and results of treatment in an outbreak of acute hemorrhagic conjunctivitis in southern Florida. Am J Ophthalmol. 1983 Jan. 95(1):45-54. [Medline].
Arnow PM, Hierholzer JC, Higbee J. Acute hemorrhagic conjunctivitis: A mixed virus outbreak among Vietnamese refugees on Guam. Am J Epidemiol. 1977. 105:69.
Jacobson LM, Redd JT, Schneider E, et al. Outbreak of lower respiratory tract illness associated with human enterovirus 68 among American Indian children. Pediatr Infect Dis J. 2012 Mar. 31(3):309-12. [Medline].
Marier R, Rodriguez W, Chloupek RJ, Brandt CD, Kim HW, Baltimore RS. Coxsackievirus B5 infection and aseptic meningitis in neonates and children. Am J Dis Child. 1975 Mar. 129(3):321-5. [Medline].
Berlin LE, Rorabaugh ML, Heldrich F, Roberts K, Doran T, Modlin JF. Aseptic meningitis in infants < 2 years of age: diagnosis and etiology. J Infect Dis. 1993 Oct. 168(4):888-92. [Medline].
Huang CC, Liu CC, Chang YC, Chen CY, Wang ST, Yeh TF. Neurologic complications in children with enterovirus 71 infection. N Engl J Med. 1999 Sep 23. 341(13):936-42. [Medline].
Cherry JL, Soriano F, Jahn CL. Search for perinatal enterovirus infection. Am J Dis Child. Sept/1968. 116(3):245-50.
Lukashev AN, Koroleva GA, Lashkevich VA, Mikhailov MI. [Enterovirus 71: epidemiology and diagnostics]. Zh Mikrobiol Epidemiol Immunobiol. 2009 May-Jun. 110-6. [Medline].
Du Z, Huang Y, Lawrence WR, Xu J, Yang Z, Lu J, et al. Leading Enterovirus Genotypes Causing Hand, Foot, and Mouth Disease in Guangzhou, China: Relationship with Climate and Vaccination against EV71. Int J Environ Res Public Health. 2021 Jan 2. 18 (1):[Medline].
Fowlkes AL, Honarmand S, Glaser C, et al. Enterovirus-associated encephalitis in the California encephalitis project, 1998-2005. J Infect Dis. 2008 Dec 1. 198(11):1685-91. [Medline].
Roden VJ, Cantor HE, O'Connor DM, Schmidt RR, Cherry JD. Acute hemiphegia of childhood associated with Coxsackie A9 viral infection. J Pediatr. 1975 Jan. 86(1):56-8. [Medline].
Whitley RJ, Cobbs CG, Alford CA Jr, et al. Diseases that mimic herpes simplex encephalitis. Diagnosis, presentation, and outcome. NIAD Collaborative Antiviral Study Group. JAMA. 1989 Jul 14. 262(2):234-9. [Medline].
Barak Y, Schwartz JF. Acute transverse myelitis associated with ECHO type 5 infection. Am J Dis Child. 1988 Feb. 142(2):128. [Medline].
Rotbart HA, Brennan PJ, Fife KH, et al. Enterovirus meningitis in adults. Clin Infect Dis. 1998 Oct. 27(4):896-8. [Medline].
Mathes EF, Oza V, Frieden IJ, et al. "Eczema coxsackium" and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013 Jul. 132(1):e149-57. [Medline].
Begier EM, Oberste MS, Landry ML, et al. An outbreak of concurrent echovirus 30 and coxsackievirus A1 infections associated with sea swimming among a group of travelers to Mexico. Clin Infect Dis. 2008 Sep 1. 47(5):616-23. [Medline].
Chung WH, Shih SR, Chang CF, et al. Clinicopathologic Analysis of Coxsackievirus A6 New Variant Induced Widespread Mucocutaneous Bullous Reactions Mimicking Severe Cutaneous Adverse Reactions. J Infect Dis. 2013 Aug 30. [Medline].
Pozzetto B, Gaudin OG, Aouni M, Ros A. Comparative evaluation of immunoglobulin M neutralizing antibody response in acute-phase sera and virus isolation for the routine diagnosis of enterovirus infection. J Clin Microbiol. 1989 Apr. 27(4):705-8. [Medline]. [Full Text].
Trabelsi A, Grattard F, Nejmeddine M, Aouni M, Bourlet T, Pozzetto B. Evaluation of an enterovirus group-specific anti-VP1 monoclonal antibody, 5-D8/1, in comparison with neutralization and PCR for rapid identification of enteroviruses in cell culture. J Clin Microbiol. 1995 Sep. 33(9):2454-7. [Medline]. [Full Text].
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].
Halonen P, Rocha E, Hierholzer J, et al. Detection of enteroviruses and rhinoviruses in clinical specimens by PCR and liquid-phase hybridization. J Clin Microbiol. 1995 Mar. 33(3):648-53. [Medline].
Archimbaud C, Chambon M, Bailly JL, et al. Impact of rapid enterovirus molecular diagnosis on the management of infants, children, and adults with aseptic meningitis. J Med Virol. 2009 Jan. 81(1):42-8. [Medline].
Xiao XL, Wu H, Li YJ, et al. Simultaneous detection of enterovirus 70 and coxsackievirus A24 variant by multiplex real-time RT-PCR using an internal control. J Virol Methods. 2009 Jul. 159(1):23-8. [Medline].
Avner E, Satz J, Plotkin SA. Hypoglycorrhachia in young infants with viral meningitis. J Pediatr. 1975. 87:883.
Garg A, Shiau J, Guyatt G. The ineffectiveness of immunosuppressive therapy in lymphocytic myocarditis: an overview. Ann Intern Med. 1998 Aug 15. 129(4):317-22. [Medline].
Goland S, Czer LS, Siegel RJ, et al. Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy: series of six patients and review of literature. Can J Cardiol. 2008 Jul. 24(7):571-4. [Medline]. [Full Text].
Rotbart HA, Webster AD. Treatment of potentially life-threatening enterovirus infections with pleconaril. Clin Infect Dis. 2001 Jan 15. 32(2):228-35. [Medline].
Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995 Aug 3. 333(5):269-75. [Medline].
Brunetti L, DeSantis ER. Treatment of viral myocarditis caused by coxsackievirus B. Am J Health Syst Pharm. 2008 Jan 15. 65(2):132-7. [Medline].
Engelmann I, Dewilde A, Lazrek M, Batteux M, Hamissi A, Yakoub-Agha I, et al. In Vivo Persistence of Human Rhinoviruses in Immunosuppressed Patients. PLoS One. 2017 Feb 2. 12 (2):e0170774. [Medline].
Kew O, Morris-Glasgow V, Landaverde M, et al. Outbreak of poliomyelitis in Hispaniola associated with circulating type 1 vaccine-derived poliovirus. Science. 2002 Apr 12. 296(5566):356-9. [Medline].
Combined immunization of infants with oral and inactivated poliovirus vaccines: results of a randomized trial in The Gambia, Oman, and Thailand. WHO Collaborative Study Group on Oral and Inactivated Poliovirus Vaccines. J Infect Dis. 1997 Feb. 175 Suppl 1:S215-27. [Medline].
Sutter RW, John TJ, Jain H, et al. Immunogenicity of bivalent types 1 and 3 oral poliovirus vaccine: a randomised, double-blind, controlled trial. Lancet. 2010 Nov 13. 376(9753):1682-8. [Medline].
Lalani S, Gew LT, Poh CL. Antiviral peptides against Enterovirus A71 causing hand, foot and mouth disease. Peptides. 2021 Feb. 136:170443. [Medline].
Li J, Yin X, Lin A, Nie X, Liu L, Liu S, et al. EV71 vaccination impact on the incidence of encephalitis in patients with hand, foot and mouth disease. Hum Vaccin Immunother. 2021 Jan 31. 1-4. [Medline].
Wadia NH, Katrak SM, Misra VP, et al. Polio-like motor paralysis associated with acute hemorrhagic conjunctivitis in an outbreak in 1981 in Bombay, India: clinical and serologic studies. J Infect Dis. 1983 Apr. 147(4):660-8. [Medline].
Majer A, McGreevy A, Booth TF. Molecular Pathogenicity of Enteroviruses Causing Neurological Disease. Front Microbiol. 2020. 11:540. [Medline].

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Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Smeeta Sinha, MD Resident Physician, Department of Dermatology, Rutgers New Jersey Medical School

Smeeta Sinha, MD is a member of the following medical societies: Alpha Omega Alpha, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS † Professor, Department of Medicine, Rutgers New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Alexander Velazquez, MD Fellow, Department of Infectious Diseases, Orlando Regional Medical Center

Alexander Velazquez, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Pratibha Dua, MD, MBBS Staff Physician, Internal Medicine, United Medical Park

Pratibha Dua, MD, MBBS is a member of the following medical societies: American Medical Association

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Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

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Additional Contributors

Mark R Wallace, MD, FACP, FIDSA Infectious Disease Physician, Skagit Valley Hospital, Skagit Regional Health

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Mary D Nettleman, MD, MS, MACP Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine

Mary D Nettleman, MD, MS, MACP is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical and Translational Research, Infectious Diseases Society of America, Society of General Internal Medicine

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