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Snapshot
  • A 16-year-old boy presents to the emergency room for chest pain and shortness of breath. He has no history of congenital heart disease. He recently attended a month-long camp with other teenagers, several of whom had viral illnesses. On physical exam, he has marked tachycardia and a low-grade fever. An echo shows left ventricular dysfunction and a cardiac magnetic resonance imaging reveals myocarditis. Serology confirms that the etiology is viral.
Introduction
  • Classification
    • coxsackievirus
      • an enterovirus that belongs to the picornavirus family
      • non-enveloped, icosahedral capsid, linear, single-stranded, positive-sense RNA virus
      • transmission via oral secretions or feces
      • coxsackievirus type A
        • hand, foot, and mouth disease
        • herpangina
      • coxsackievirus type B
        • most commonly causes nonspecific prodrome
        • myocarditis
        • pericarditis
  • Epidemiology
    • incidence
      • common in children
    • demographics
      • more common in children
    • risk factors
      • exposure to others with the virus
      • daycare centers
      • poor hygiene
      • finger sucking
  • Pathogenesis
    • once infected, the virus will travel to the lymph nodes and incubate, causing a prodrome
  • Prognosis
    • typically spontaneously resolves
Presentation
  • Hand, foot, and mouth disease
    • vesicles on the palms and soles
    • may also be erythematous papules
    • vesicles and ulcers in oral mucosa
  • Herpangina
    • ulcers and vesicles in oral mucosa
  • Myocarditis
    • heart failure
    • chest pain
    • arrhythmias
    • tachycardia out of proportion to fever
  • Pericarditis
    • sharp pleuritic chest pain
      • relieved by sitting up and forward
    • friction rub on exam
Studies
  • Labs
    • coxsackievirus-specific immunoglobulin A
    • viral culture
  • Making the diagnosis
    • based on clinical presentation but may be confirmed with laboratory studies
Differential
  • Rickettsia rickettsii infection
    • distinguishing factor
      • also presents with rash on palms and soles but is often not macular and not vesicular in nature
  • Chickenpox
    • distinguishing factor
      • itchy vesicular rash that typically does not occur on the palms, soles, and oral mucosa
Treatment
  • Management approach
    • mainstay of treatment is supportive care and treating any organ failure (such as heart failure in myocarditis)
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • antipyretics
        • analgesics
        • hydration
Complications
  • Aseptic meningitis
  • Guillain-Barre syndrome
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