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Updated: Sep 10 2018


  • 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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