Snapshot A 4-year-old girl is brought to the emergency room in July for fevers, headache, and rash. Her symptoms first occurred yesterday with subjective fevers and some photophobia. She developed a diffuse rash throughout her body. Her mother states she has been visiting a neighborhood public pool every week for the entire summer. On physical exam, she has nuchal rigidity and a scattered maculopapular rash on her chest, back, and legs. Her parents are counseled on the need for a lumbar puncture for further evaluation to rule out other causes of meningitis. Introduction Classification echovirus a non-enveloped, linear, single-stranded, positive-sense RNA virus with an icosahedral capsid a picornavirus and enterovirus transmission via fecal-oral causes aseptic meningitis Epidemiology incidence common cause of aseptic meningitis peaks in summer and fall demographics male > female children > adults location central nervous system risk factors immunosuppressed status exposure to others with echovirus public swimming pool Pathogenesis echovirus binds to decay-accelerating factor, a receptor the virus then replicates in Peyer’s patches it travels to regional lymph nodes and central nervous system Prognosis most infections with echovirus are asymptomatic neonates with aseptic meningitis are at highest risk of death with mortality up to 10% Presentation Symptoms prodrome with fever, nausea, vomiting, or rash headache stiff neck photophobia irritability Physical exam nuchal rigidity papilledema scattered maculopapular rash Studies Labs cerebrospinal fluid (CSF) studies ↑ white blood cells normal protein normal glucose detection of RNA on reverse transcriptase-polymerase chain reaction (RT-PCR) Making the diagnosis based on clinical presentation and laboratory studies Differential Bacterial meningitis distinguishing factor CSF with decreased glucose and increased protein Treatment Management approach mainstay of treatment is supportive care Conservative supportive care indication all patients modalities hemodynamic support Complications Seizures Myocarditis Guillain-Barre syndrome