Like many contagious respiratory or intestinal illnesses, once the coxsackievirus enters the body, it takes an average of 1-2 days for symptoms to develop (incubation period).
People are most contagious in the first week of illness, but the virus may still be present up to 1 week after symptoms resolve. The virus may reside longer in children and those whose immune system is weak.
Coxsackievirus is spread from person to person. The virus is present in the secretions and bodily fluids of infected people. The virus may be spread by coming into contact with respiratory secretions from infected patients. If infected people rub their runny noses and then touch a surface, that surface can harbor the virus and become a source of infection. The infection is spread when another person touches the contaminated surface and then touches his or her mouth or nose.
People who have infected eyes (conjunctivitis) can spread the virus by touching their eyes and touching other people or touching a surface. Conjunctivitis may spread rapidly and appear within 1 day of exposure to the virus. Coxsackieviruses are also shed in stool, which may be a source of transmission among young children. The virus can be spread if unwashed hands get contaminated with fecal matter and then touch the face. This is particularly important for spread within day-care centers or nurseries where diapers are handled. Diarrhea is the most common sign of coxsackievirus intestinal infection.
Most coxsackievirus infections are mild and may not even cause symptoms. The virus is one cause of the common cold or a generalized mildly erythematous (red) rash, especially seen in the summer months. It may also cause diarrhea or a sore throat that is similar to strep throat.
There are some more severe syndromes caused by the virus, but these are less common. They include meningitis (an infection of the linings of the spinal cord and brain), encephalitis (inflammation of the brain), pleurodynia (chest pain), and myopericarditis (inflammation of the heart). Infection of newborns may be particularly severe. These syndromes are described below.
It is common for the coxsackievirus to cause a febrile upper respiratory tract infection with sore throat and/or a runny nose. Some patients have a cough resembling bronchitis. Less commonly, coxsackievirus may cause pneumonia.
Some people with coxsackievirus have a rash. In many, this is a nonspecific generalized red rash or clusters of fine red spots. The rash may not appear until the infection has started to get better. Although it may resemble a light sunburn, the rash does not peel. The rash itself is not contagious.
The virus may also cause small, tender blisters and red spots on the palms, soles of the feet, and inside the mouth. In the mouth, sores occur on the tongue, gums, and cheek. This condition is known as hand-foot-mouth disease (HFMD) and is caused by group A coxsackievirus. HFMD is most common in children under 10 years of age. HFMD usually causes a sore throat, fever, and the characteristic blister rash described above. It is mild and resolves on its own. While the blister fluid is a theoretical source of transmission of the virus, the large majority of those infected develop HFMD from contact with respiratory droplets or stool exposure.
Coxsackievirus also may cause a syndrome called herpangina in children. Herpangina presents with fever, sore throat, and small, tender blisters inside the mouth. It is more common in summer and is usually found among children 3-10 years of age. It may be confused with strep throat at first until test results for strep come back negative.
Acute hemorrhagic conjunctivitis (AHC) presents with swollen eyelids and red hemorrhages in the whites of the eye. Usually, the infection spreads to the other eye as well. Affected people may feel like there is something in their eye or complain of burning pain. AHC may be caused by coxsackievirus, although it is more commonly caused by a related virus. Symptoms usually resolve in about a week.
Coxsackieviruses, especially those from group B, may cause viral meningitis (inflammation of the linings of the spinal cord and brain). Viral meningitis is also known as "aseptic meningitis" because routine cultures of the spinal fluid show no bacterial growth. This is because routine culture methods test for bacteria and not for viruses. Patients with aseptic meningitis complain of a headache and fever with mild neck stiffness. A rash may be present. In children, symptoms may be less specific, including change in personality or becoming lethargic. Febrile seizures may occur in children. Seizures are less common in adults, although adults may complain of fatigue that lasts for weeks after the meningitis resolves.
Less commonly, coxsackievirus may cause inflammation of the brain tissue (meningoencephalitis), as well. People with meningoencephalitis usually have fever and are lethargic or confused. Meningoencephalitis is more common in small children.
Another rare symptom is weakness in an arm or leg or even partial paralysis. The symptoms are similar to, but milder than, those caused by poliomyelitis. Paralysis or weakness may follow a bout of AHC or may occur on its own. Weakness and paralysis caused by coxsackievirus usually are not permanent.
Pleurodynia is an inflammation of the muscles in the chest. It causes a sudden onset of sharp chest pain which gets worse when taking a deep breath. Pain may also be present in the abdomen. The pain comes and goes in waves or spasms. Pleurodynia generally resolves on its own in about 5 days, although it may recur over the next few weeks.
A very serious problem caused by coxsackievirus is an infection of the heart and lining of the heart (myopericarditis). Fortunately, this complication is quite rare. Myopericarditis symptoms may vary from mild to severe. Severe cases may result in heart failure, heart attack or death. Myopericarditis is more common in young, active adults. Symptoms include shortness of breath, chest pain, fatigue, and leg swelling. The injury to the heart may be transient or permanent.
Newborns may acquire the virus from infected adults or children. Outbreaks of group B coxsackievirus infections have occurred in nurseries. Infection may be transmitted during pregnancy at the time of delivery as the infant comes into contact with the mother's secretions. Some infected babies will have a mild illness, but infants are at higher risk to have severe disease than older children. Severely affected infants become listless or unresponsive and may have myopericarditis/heart failure, pneumonia, or an inflamed liver (hepatitis) or liver failure. Diarrhea may cause dehydration in infants and may be severe enough to be life-threatening or fatal.
People born with defects in the immune system and those who are taking immunosuppressive medicines (for example, after bone marrow transplants) are susceptible to more severe and prolonged infection with coxsackievirus.
Coxsackievirus may infect the testicles of young boys (orchitis) causing inflammation and swelling similar to mumps. The virus may also cause a syndrome that is similar to mononucleosis with an enlarged spleen and sore throat.
In people with symptoms of a common cold or a rash, no tests are usually needed. In people with conjunctivitis, the doctor may examine the eyes using a handheld ophthalmoscope to confirm the diagnosis. If a sore throat is present, the doctor may take a swab and do a rapid test to rule out strep throat.
In aseptic meningitis, a doctor may take a sample of the spinal fluid by doing a spinal tap (lumbar puncture). Most patients with aseptic meningitis will show an increase in the number of white cells in the spinal fluid, a normal sugar level, and normal to slightly elevated protein level in the fluid. These changes in the spinal fluid are much milder than would be seen with bacterial meningitis. A sample of the spinal fluid may be cultured to see if it grows coxsackievirus, but culture is difficult and expensive and many hospitals do not have the ability to do it. More recently, a rapid test called the polymerase chain reaction (PCR) has been used that detects the genetic material of the virus. The PCR can detect 66%-90% of infections.
Myopericarditis is a serious condition and requires evaluation with an electrocardiogram (ECG or EKG) and an ultrasound of the heart (echocardiogram). The electrocardiogram may show rhythm problems caused by the enlargement of the heart and may reveal whether the sac around the heart is inflamed. The echocardiogram shows how large the heart is, how well it pumps blood, and whether there is fluid around the heart. Blood tests are done to tell if other organs are being damaged.
There is no specific medicine that has been shown to kill the coxsackievirus. Fortunately, the body's immune system is usually able to destroy the virus. In cases of severe disease, physicians have sometimes turned to therapies that seem promising but which have not been thoroughly tested to see if they really work. For example, some reports suggest there might be a benefit to intravenous immune globulin (IVIG), which is made from human serums, which contains antibodies.
Treatment for myopericarditis is supportive. This includes using medicines to support the blood pressure if the heart is pumping too poorly to do so by itself. In extreme cases, heart transplantation may be needed.
Acetaminophen, ibuprofen, and similar agents can be used to reduce pain and fever. Avoid the use of aspirin in children and teenagers, because of the risk of a serious liver disorder (Reye's syndrome).
Over-the-counter cold preparations (decongestants, cough syrup) may reduce symptoms in adults, although they will not speed recovery and may cause side effects including drowsiness and dry mouth. The efficacy of these products has recently been challenged by the U.S. Food and Drug Administration (FDA), which recommends against their use in children under 6 years of age. There are no studies showing that over-the-counter medicines work in older children.
Frequent hand washing by both sick and well people is the key to reducing transmission. Plain soap and water are effective as are the alcohol-based products now on the market. People who are sneezing or coughing should cover their mouths. Diapers and fecal waste should be handled carefully and disposed of properly. Surfaces should be kept clean. Contaminated surfaces should be disinfected using a dilute solution of household bleach (1 tablespoon of bleach to 4 cups of water).
Interestingly, some scientists have proposed a link between coxsackievirus and the onset of juvenile (type I) diabetes. Among other things, this is based on evidence showing that development of type I diabetes is more common in the months after viruses like coxsackievirus circulate in the population. However, the link is far from proven and requires significantly more study.
The search for a vaccine against coxsackievirus has not yet been successful. However, efforts are continuing.
Most rashes caused by viruses do not harm a child and go away over time without any treatment. However, some childhood rashes have serious or even life-threatening causes. Parents should be familiar with these rashes. Many rashes can look the same, making it difficult to know the exact diagnosis. See a doctor immediately for any concerns.
