Enteroviruses Workup: Laboratory Studies, Imaging Studies, Other Tests

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Sections Enteroviruses
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- History
- Physical
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Workup

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.^[58]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%.^[59]

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%.^{[60, 61]}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.^[62]

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.^[63]

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,^[64]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

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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

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

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

Disclosure: Nothing to disclose.

Sections Enteroviruses
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
References

Enteroviruses Workup

Laboratory Studies

Serology

Viral isolation

Polymerase chain reaction

Cardiac enzyme levels

CSF analysis

Imaging Studies

Other Tests

Histologic Findings

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