Coxsackie Virus Infection

The coxsackie viruses are RNA viruses of the picornavirus group that include ECHO, polio and enteroviruses. Infections are often asymptomatic. They are divided into groups A and B.

• Coxsackie A cause herpangina and hand-foot-and-mouth disease.
• Coxsackie B viruses cause Bornholm disease as well as myocarditis, and pericarditis.

It is named after the town of Coxsackie in New York state.

Infection is common but most frequent in summer and autumn in temperate climates but all year round in the tropics. They tend to affect those under 16 but adults are also affected.

Spread is usually from the faeco-oral route with an incubation period of 2 to 6 days.

• Herpangina has an incubation period of about 4 days. Mild pyrexia, headache, sore throat, dysphagia, loss of appetite and sometimes vomiting and abdominal pain occur. Tiny grey-white papulo-vesicles, about 1 or 2 mm in diameter, appear on the uvula, soft palate and tonsils. There is an erythematous halo, which progresses to a shallow ulcer. It is caused mainly by Coxsackie and it resolves uneventfully in 5 to 10 days.
• Hand foot and mouth disease is caused by Coxsackie A and is described elsewhere.
• Bornholm disease affects the intercostal muscles. Pain on inspiration is similar to pleuritic pain and pulmonary embolism may be suspected. The muscles are locally tender. There will be no haemoptysis. There may be a slight sensation of dyspnoea or pain on breathing.
• Myocarditis is usually asymptomatic but it is a reason not to do strenuous exercise when pyrexial as under these circumstances myocarditis may cause ventricular fibrillation and death. Intrauterine infection can result in death from myocarditis.
• Pericarditis is discussed elsewhere.
• Coxsackie B5 causes pustular stomatitis with erythema multiforme.
• Coxsackie A4 causes a widespread vesicular eruption.

• Aphthous ulcers
• Drug Eruptions
• Herpes Simplex
• Rubella

Usually diagnosis is clinical but some laboratory tests are available. The most specific findings are found in samples from the blood and vesicles. Faecal specimens are less useful.

• IgM with immunosorbent assay (ELISA) can aid diagnosis. Blood samples are required in the acute phase because IgM disappears rapidly.
• Cell culture of the virus is possible.
• Polymerase chain reaction (PCR) has made enteroviral subtyping possible but it is difficult and expensive and not routinely performed.

• If acquired in the first trimester of pregnancy they can cause spontaneous abortion or intrauterine growth retardation.¹ The association with early abortion is disputed.²
• There is evidence that some cases of late fetal loss and otherwise unexplained neonatal death may be associated with Coxsackie infection.³ The virus may be transmitted across the placenta, acquired from maternal secretions during delivery or acquired in the nursery after birth. Transmission from mother to infant occurs in 30 to 50% of cases.²
• Coxsackie infection has also been linked over the years to a number of other diseases including chronic fatigue syndrome (CFS), formerly called myalgic encephalitis (ME),⁴ although this finding is not invariable.⁵
• The development of type I diabetes may be related,⁶ especially if the infection occurred in utero.

Mouth rinses with topical anaesthetics can ease the pain. Antipyretic analgesics such as paracetamol and ibuprofen are the main treatment. Antiviral agents are not indicated.

These diseases tend to be self-limiting. They are very common in pregnancy, especially at times of the year when prevalence is high, but the outcome is usually benign if the mother was asymptomatic. As many as 65% of women who give birth to infants with proven enteroviral infection have symptomatic disease during the perinatal period. Maternal echovirus or Coxsackie virus B infections are not associated with an increased risk of spontaneous abortions, but stillbirths late in pregnancy have been described.²

Coxsackie infection tends to be seen as a trivial and self limiting infection but perhaps we should consider it as more like rubella that is also trivial and self limiting except in pregnancy. Whereas rubella is a problem in early pregnancy, Coxsackie appears to be a danger in the late stages.

Hand washing reduces spread within the family. There is no vaccine against Coxsackie viruses.