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