CXA, CXB, ECH, Coxsackie viruses & Echoviruses

Clinic

• Coxsackieviruses are a few related Enteroviruses
• Enteroviruses also includes PLV and ECHO, therefore Coxsackieviruses share many characteristics with PLV
• Coxsackieviruses are divided into group A and group B
  • Group A cause a flaccid paralysis due to generalized myositis.
  • Group B cause a spastic paralysis due to focal muscle injury and degeneration of neuronal tissue.

• At least 23 serotypes (1–22, 24) of group A and 6serotypes (1–6) of group B are recognized.

CXA

• The most well-known Coxsackie A disease is hand, foot and mouth disease
• Herpangina: Painful blisters in the mouth, palms, fingers, soles, throat and tonsils. palms, fingers, soles, throat tonsils.
• Itchy / Painful Rashes on the Hands/ Fingers / Feet soles/ several conjunctivitis
• Acute conjunctivitis (A24 specifically)
• CXA-7 infrequently causes polio-like permanent paralysis.

Specific entities

• Acute hemorrhagic Conjunctivitis:
  • Watery discharge
  • Lachrymation.
  • Pain; burning. Swelling of eyelids.
  • Burning. Subconjunctival bleeding ,
  • Conjunctival edema

• Soft palate Ulceration
  • Mouth Dryness.
  • Sore mouth.
  • Koplik's spots, macular, vesicular Eruptions on soft palate, tongue
  • Erythematous. Vesicles; between tonsils and uvula, posterior pharyngeal wall, tonsils

• Lymphonodular Pharyngitis, Tonsillitis:
  • Sore throat: Painful swallowing / Throat Dryness
  • Exudation
  • Periauricular lymphadenopathy

• Asymmetric Flaccid paralysis, Paresis, tremor
• Hypotonia, Muscular weakness

• Eruptions; macular, morbilliform, papular, roseoliform, rubelliform, vesicular, downward, pink, tender

Specific Disease

• Hand-foot-and-mouth disease (HFM disease)
• Guillain-Barre syndrome

CXB

• CXB causes Pleuritis, myocarditis, pericarditis, and hepatitis
• CXB infection of the heart can lead to pericardial effusion
• Insulin-dependent diabetes (IDDM) has recently been associated with recent enteroviral infection, particularly coxsackievirus B pancreatitis.

• Sjögren syndrome is also being studied in connection with coxsackievirus, as of January 2010.
• CXB is a group of six serotypes of Coxsackievirus, that trigger illness ranging from GI distress to pericarditis and myocarditis (Coxsackievirus-induced cardiomyopathy).

Specific entities

• Pericarditis:
  • Pericardial friction rub
  • Pleurodynia: Sharp / Burning / Lancinating / Spasmodic / Stitching / Stabbing / Constricting / Paroxysmal, pain in Costal margin, intercostal, Precordial, Subxiphoid

• Myocarditis:
  • Arrythmia
  • Tachycardia
  • Cardiomegaly / Dilated heart / Congestive Heart failure
  • Angina pectoris,
  • Pulmonary edema

• Pancreatitis: Diarrhea
• IDDM

Common Entities

Common Entities	Sign / Symptoms	Diseases
Aseptic Meningitis	Meningismus Headache Cervical rigidity Buldging fontanelles in infants. Papilledema
Encephalitis	Restlessness , Anxiety, Irritability Personality change / Behvioral change, Hyperactivity, Cognition impaired Coma / Sleepiness / Sleeplessness Seizure (Complex, Partial motor, Febrile)
Bulbar palsy
Transverse myelitis:	Paresthesia Sharp, lancinating, spasmodic, stitching, stabbing, constricting, paroxysmal, Burning pain in Costal, intercostal, Pectoralis major, Precordial, Subxiphoid Motion agg Radicular pain
Neuritis	Vestibular, Brachial, Radicular pain
Keratitis	Sensation of a foreign body Photophobia
Gastroenteritis	Stomach Pain / Eructations Epigastrium, hypochondrium, lancintaing, stitching Spasmodic or sharp in upper abdominal Peri-umbilical, lower abdominal
Thrombocytopenia	Splenomegaly Petechiae , Purpura Bleeding. Ecchymoses, Epistaxis
Hepatitis	Hepatomegaly Vomiting Hepatic transaminases rised Jaundice Lethargy	Fulminant Hepatitis
	Lymphadenopathy, Lymphocytosis
Interstitial Pneumonia	Dyspnea. Respiratory Distress / Failure Cough
Croup, Laryngitis
Tracheitis Bronchitis Bronchopneumonia
Bronchiolitis
		Renal failure
Genital Eruptions
Orchitis	Painful swelling testis
Myositis	Dermatomyositis-like illness Myalgia (Trapozious, Erector spina, Pectoralis major ) Myoglobinemia, Myoglobinuria	Generalized Myositis
Arthritis
Pharyngitis Tonsillitis, exudative
Mouth ulceration, Stomatitis
Labyrinthitis
ChoreaAthetosis	Hemichorea	Tic
Belpharitis
Cerebellar Ataxia	Incoordination
Thyroiditis		Hashimoto thyroiditis
	Tremor
	Visual filed deficit
	Opsoclonus	Opsoclonus Myoclonus
	Hypotension

Both groups cause nonspecific febrile illnesses, rashes, upper respiratory tract disease

Generality:

• Periodicity
• Anorexia, Poor feeding, Malaise, Muscles Weakness
• Upper respiratory symptoms
• Nigh Fever + perspiration + Chill

• Summer grippe: Coryza

Diseases

• Cerebral palsy

• Reye's syndrome
• Papular acrodermititis (Gianotti-crosti syndrome)

New researches

• CXB frequently infect CNS causing neurological diseases notably meningitis and encephalitis.
• These infections occur principally among newborns and children.
• Epidemiological studies of patients with nervous system disorders demonstrate the presence of infectious virus, its components, or anti-CV-B antibodies.
• Some experimental studies support the potential association between CXB and ALS and schizophrenia.
• The proposed mechanisms focus on the immune response following the viral infection as a contributor to pathogenesis.
• Severe HFMD is a fatal paediatric disease which has long-term neurocognitive consequences such as attention deficit hyperactivity disorder and Autism spectrum disorder.
• About 3% of enterovirus infected people will develop encephalitis while most people never show evidence of CNS infection
• There has been growing interest in the association between infectious disease and mental disorders, but an association between enterovirus (EV) infection and tic disorders has not been sufficiently explored. A total of 47,998 individuals with history of EV infection were compared to 47,998 of tic disorders. EV infection is temporally associated with incidence of tic disorders. Our observations add to the growing body of literature implicating immune-inflammatory system in the pathoetiology of brain disorders in a subpopulation of individuals and serve as a clarion call for surveillance of symptoms suggestive of tic disorders in individuals with history of EV infection.

From 2010 to 2012, large outbreaks of EV-A71-related- hand foot and mouth disease (HFMD) occurred annually in China. Some cases had neurological complications and were closely associated with fatal cardiopulmonary collapse, but not all children with central nervous system (CNS) involvement demonstrated a poor prognosis. To identify which patients and which neurological complications are more likely to progress to cardiopulmonary failure, we retrospectively studied 1,125 paediatric inpatients diagnosed with EV-A71-related HFMD in Hunan province, including 1,017 cases with CNS involvement. These patients were divided into cardiopulmonary failure (976 people) group and group without cardiopulmonary failure (149 people). A logistic regression analysis was used to compare the clinical symptoms, laboratory test results and neurological complications between these two groups. The most significant risk factors included young age, fever duration ≥3 days, coma, limb weakness, drowsiness and ANS involvement. Patients with brainstem encephalitis and more CNS-involved regions were more likely to progress to cardiopulmonary failure. These findings can help front-line clinicians rapidly and accurately determine patient prognosis, thus rationally distributing the limited medical resources and implementing interventions as early as possible.

Remedies

1. Phos, Sul, Ars
2. Zinc, Rhus-t, Bell, Calc, Lach, Merc, Apis, Hep, Cupr, Acon, Arg-m, Agar, Arg-n, Brom, Caust, Cocc, Nat-m