Picornavirus Infections Clinical Presentation

Updated: Apr 24, 2018
  • Author: Shivan Shah, MD; Chief Editor: Michael Stuart Bronze, MD  more...
  • Print


The following summary intends to cover general clinical symptomatology for major members of the Picornaviridae family.

Enteroviral infection symptoms  [33]

Poliovirus: Manifestations of infection range from inapparent illness to severe paralysis and death.

Abortive poliomyelitis virus infection is characterized by 2-3 days of fever, headache, sore throat, listlessness, anorexia, vomiting, and abdominal pain. Findings of neurologic examination are normal.

Nonparalytic poliomyelitis is similar to the abortive form but produces meningeal irritation.

Spinal paralytic poliomyelitis has a biphasic course. The minor illness coinciding with viremia corresponds to the symptoms of abortive polio and lasts 1-3 days. The patient then appears to be recovering and remains symptom-free for 2-5 days before the abrupt onset of the major illness. Meningitis is the preparalytic symptom of the major illness. Meningismus and accompanying muscle pain are generally present for 1-2 days before frank weakness and paralysis ensue. The paralysis is flaccid, asymmetric in distribution. Proximal muscles of the extremities tend to be more involved than distal muscles; the legs are more commonly involved than the arms.

Bulbar paralytic poliomyelitis consists of paralysis of muscle groups innervated by cranial nerves, especially those of the soft palate and pharynx, resulting in dysphagia, nasal speech, and some dyspnea.

Polioencephalitis is characterized by disturbances of consciousness, occurring predominantly in infants. This condition is the only type of poliomyelitis in which seizures are common.

Systemic infections caused by enteroviruses other than polioviruses  [29]

CNS: Enterovirus 71 is a prominent cause of CNS infections, including encephalitis. [34]

Heart: Coxsackievirus B in particular causes acute myocarditis and pericarditis.

Skeletal muscles: Pleurodynia (Bornholm disease) is also usually caused by coxsackievirus B and is characterized by fever and severe pain in the chest. If the diaphragm is involved, severe pain develops in the abdomen. Symptoms last for a few days to 2 weeks and resolve without ill effects. Individuals who develop myalgic encephalomyelitis (ME), another syndrome, have few, if any, physical signs, but many symptoms develop. The most prominent symptoms include fatigue, following even minor physical activity, and depressive psychological illness.

Skin and mucous membranes: Enteroviral infections of these tissues are caused almost entirely by coxsackievirus A. Rashes may accompany infections of other systems. Herpangina is a painful infection of the pharynx with herpeslike features (eg, vesicles of the soft palate, fauces, uvula, posterior wall of the pharynx). The infection resolves spontaneously in a few days. In hand-foot-and-mouth disease (HFMD) unrelated to the FMD of cattle, vesicles and ulcers develop in the anterior part of the mouth, followed by a vesicular rash on the hands and feet. [35]

Conjunctiva: Infection is characterized by subconjunctival hemorrhage, severe pain in the eyes, photophobia, and occasional keratitis. Coxsackievirus A24 and echovirus 70 are the main causes of this infection.

Rhinoviruses  [15, 36, 37]

Rhinoviruses produce the common cold, which usually lasts no more than 7 days.

In most cases, rhinorrhea and nasal obstruction are the most prominent complaints.

The throat is frequently sore or scratchy. Cough and hoarseness occur in 33% of all cases.

Hepatitis A  [26]

HAV has an incubation period of 2-6 weeks, with an average of 28 days. Many infections are silent, particularly in small children.

Clinical illness usually starts in a few days, with symptoms of malaise, anorexia, vague abdominal discomfort, and fever. Later, the urine becomes dark and the feces appear pale.

Soon afterwards, jaundice appears, first in the sclera and then in the skin; if severe, itching may accompany these symptoms. The patient starts to feel better within the next week or so, and the jaundice disappears within a month.



Physical examination findings depend on the infection, and a given virus and strain can produce variable symptoms in different patients. [26, 15, 33, 29]



Complications of hepatitis A virus infection include the following: [26]

  • Cholestasis
  • Relapsing disease
  • Fulminant hepatitis, particularly in patients with underlying liver disease or chronic viral hepatitis
  • Chronic, active autoimmune hepatitis

Complications of infections with enteroviruses include the following: [29]

  • Respiratory compromise is caused by paralysis of the respiratory muscles, by airway obstruction due to involvement of cranial nerve nuclei, or by respiratory center lesions.
  • Postpolio syndrome (new onset weakness, fatigue, breathing or sleeping difficulty, myalgias and/or arthralgias) may affect poliomyelitis survivors months to years after recovery.
  • Gastrointestinal events (eg, hemorrhage, paralytic ileus, gastric dilatation) may complicate acute paralysis.
  • Chronic nonischemic cardiomyopathy and pneumonitis has been associated with coxsackieviruses. [24]
  • Fatal encephalitis has been observed in enterovirus 71 infections. [34, 20]
  • Echovirus and parechovirus infections in children treated with aspirin may lead to Reye syndrome. [38]
  • A connection between pancreatitis and diabetes mellitus type 1 is still being sought. [39, 40]

Complications of infections with rhinoviruses [15, 36]  and enteroviruses include the following: