Medical Care

No antiviral therapy has been available except IVIG therapy, which reportedly has some success in patients who are immunocompromised and have persistent enterovirus infections. The role of IVIG therapy for acute infections is unproven. A study evaluating its use in enteroviral infection in neonates failed to demonstrate a clear benefit. Another study evaluating the use of IVIG in 21 patients with myocarditis showed improved left ventricular function and survival when compared with 25 control patients. However, additional studies are needed.

Corticosteroid use to treat viral myopericarditis remains controversial at best. Several antiviral agents have in vitro activity against a broad range of enterovirus types, and several clinical trials have been conducted on their use.

The first of these agents to be studied was pleconaril, a drug that interferes with the binding of enterovirus to the cell membrane and the uncoating of virions by attaching to the virus protein capsid.^{[19, 20]}Several clinical trials have demonstrated a benefit in children and adults with enterovirus meningitis.^[21]Pleconaril apparently may be on the verge of becoming readily available for clinical use as a new therapy option for echovirus (EV) and other enteroviral infections.

Pleconaril at concentrations of 0.1 mg/mL has activity against more than 90% of the most common circulating enteroviruses. The drug has good bioavailability and a prolonged half-life, allowing oral administration 3 times a day. Adequate levels can be achieved in serum and CSF.

Pleconaril has been studied in enteroviral meningitis, in respiratory tract infections, and in a limited number of patients who are immunocompromised and have viral myocarditis.

Phase III clinical trials are underway, and initial results are promising. In the first placebo-controlled double-blind study, 221 children (aged 4-14 years) with signs and symptoms of viral meningitis, most confirmed as enterovirus with EV-PCR, received 2.5 or 5 mg/kg of pleconaril or placebo 3 times a day for 7 days.^[21]Initial findings showed a 38-50% improvement among treated patients when compared with patients receiving a placebo. Improvement was seen as early as 24 hours after therapy initiation. Similar results have been obtained in studies of adolescents and adults with enteroviral meningitis. Pleconaril is currently under investigation in a multicenter collaborative study of therapy for neonatal enteroviral sepsis sponsored by the National Institutes of Health.

Schering-Plough lists pleconaril nasal spray as having completed phase II trials for preventing asthma exacerbation and common cold symptoms in asthmatic patients exposed to picornavirus.^[20]

Pleconaril has not been approved by the US Food and Drug Administration (FDA).

Follow-up care

The specific type of infection caused by EV should dictate follow-up care.

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Author

Jorge M Quinonez, MD Senior Vice President and Chief Medical Officer, Family Health Centers of Southwest Florida, Inc

Jorge M Quinonez, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America

Disclosure: Received consulting fee from Glaxo Smith Kline for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics, Novavax, Regeneron, Diassess, Actelion<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Leonard R Krilov, MD Chief of Pediatric Infectious Diseases and International Adoption, Vice Chair, Department of Pediatrics, Winthrop University Hospital; Professor of Pediatrics, Stony Brook University School of Medicine

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, Society for Pediatric Research

Disclosure: Nothing to disclose.

Pediatric Echovirus Treatment & Management

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