CoxsackievirusesCoxsackievirusesan updatean update

Dr.T.V.Rao MD

Dr.T.V.Rao MD 1

History of Coxsackieviruses

• The Coxsackieviruses were discovered in 1948-49 by Dr. Gilbert Dalldorf, a scientist working at the New York State Department of Health in Albany, New York.

Dr.T.V.Rao MD 2

Coxsackie, New York• The virus family

discovered was eventually given the name Coxsackie, for the town of Coxsackie, New York, a small town on the Hudson River where Dalldorf had obtained the first faecal specimens

Dr.T.V.Rao MD 3

The Virus belongs to ..• Coxsackievirus is a virus that belongs to a

family of nonenvelopedd, linear, positive-sense ssRNA viruses, Picornaviridae and the genus Enterovirus, which also includes poliovirus and echovirus. Enterovirus are among the most common and important human pathogens, and ordinarily its members are transmitted by the fecal-oral route.

Dr.T.V.Rao MD 4

Coxsackie's belongs to Coxsackie's belongs to EnterovirusEnterovirus

Dr.T.V.Rao MD 5

Coxsackievirus spreadCoxsackievirus spread• They can spread

from person to person, usually on unwashed hands and surfaces contaminated by feces, where they can live for several days.

Dr.T.V.Rao MD 6

Coxsackievirus• Coxsackievirus (sometimes written as

two words, Coxsackie's virus) belongs to a group of viruses called enterovirus. Coxsackievirus infections occur most often during summer and fall

• Coxsackievirus infections occur most often in young children,

Dr.T.V.Rao MD 7

The Virus belongs to Two Groups

• Coxsackievirus are divided into group A and group B viruses based on early observations of their pathogenicity in mice. Group A coxsackieviruses were noted to cause a flaccid paralysis (which was caused by generalized myositis) while group B coxsackieviruses were noted to 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 six serotypes (1- 6 of group B are recognized.

Dr.T.V.Rao MD 8

Coxsackie's virus Infects Suckling Mice but not Adult Mice

Dr.T.V.Rao MD 9

Several Serotypes• At least 23

serotypes (1-22, 24) of group A and 6 serotypes (1-6) of group B are recognized

Dr.T.V.Rao MD 10

Sources of Coxsackie's viral infections

• Infection usually is spread by fecal-oral contamination, although occasionally the virus is spread by droplets expelled by infected individuals. Items like utensils, diaper-changing tables, and toys that come in contact with body fluids that contain the virus may also transmit them to other individuals

Dr.T.V.Rao MD 11

Coxsackie virus spread through

• They can spread from person to person, usually on unwashed hands and surfaces contaminated by feces, where they can live for several days.

Dr.T.V.Rao MD 12

Diseases Caused by Diseases Caused by CoxsackievirusCoxsackievirus

• Herpangina– coxsackie A virus

• Hand-foot-and-mouth disease– Coxsackievirus A16 and enterovirus 71

• Pleurodynia– coxsackie B virus

• Myocardial and pericardial infections –coxsackie B virus. (B3)

• Viral meningitis– Coxsackievirus or echovirus

Dr.T.V.Rao MD 13

Pathophysiologyof Coxsackie's virus

• Coxsackieviruses are transmitted primarily via the fecal -oral route and respiratory aerosols, although transmission via fomites is possible. The viruses initially replicate in the upper respiratory tract and the distal small bowel. They have been found in the respiratory tract up to 3 weeks after initial infection and in feces up to 8 weeks after initial infection. The viruses have been found to replicate in the sub mucosal lymph tissue and disseminate to the Reticuloendothelial system. Further dissemination to target organs occurs following a secondary Viremia.

Dr.T.V.Rao MD 14

Symptoms related to Symptoms related to Coxsackievirus Coxsackievirus

• Upper respiratory tract symptoms, including sore throat, rhinitis, and dry cough

• Constitutional symptoms, including headaches (50%), fever, and malaise

• GI symptoms, including nausea, vomiting, diarrhea (50%); abdominal pain (usually in the epigastria area) in children

• Testicular pain (i.e., orchids) in 10% of male

Dr.T.V.Rao MD 15

Coxsackie virus infection present with

• Both group A and group B Coxsackievirus can cause nonspecific febrile illnesses, rashes, upper respiratory tract disease, and aseptic meningitis

Dr.T.V.Rao MD 16

Coxsackie virus infection present with

• In general, group A coxsackieviruses tend to infect the skin and mucous membranes, causing herpangina, acute haemorrhagic conjunctivitis (AHC), and hand-foot-and-mouth (HFM) disease

Dr.T.V.Rao MD 17

Coxsackie virus – Can cause Acute haemorrhagic

conjunctivitis • Rare complications

include keratitis and motor paralysis.

• This condition is highly contagious and has resulted in epidemics and pandemics.

Dr.T.V.Rao MD 18

Hand, Foot, and Mouth Disease• Type of Coxsackie Virus

syndrome• Causes painful red

blisters on:– Throat– Tongue– Gums– Cheeks– Palms of hands– Soles of Feet

Dr.T.V.Rao MD 19

Coxsackievirus syndrome• Hand, foot, and mouth

disease, a type of Coxsackievirus syndrome, causes painful red blisters in the throat and on the tongue, gums, hard palate, inside of the cheeks, and the palms of hands and soles of the feet.

Dr.T.V.Rao MD 20

Herpangina,• Herpangina, an

infection of the throat which causes red-ringed blisters and ulcers on the tonsils and soft palate, the fleshy back portion of the roof of the mouth.

Dr.T.V.Rao MD 21

Hand, Foot, and Mouth DiseaseHand, Foot, and Mouth Disease

• Hand, foot and mouth disease usually affects infants and children, and is quite common. It is highly contagious and is spread through direct contact with the mucus or faeces of an infected person. It typically occurs in small epidemics in nursery schools or kindergartens, usually during the summer and autumn months.

Dr.T.V.Rao MD 22

Hand, Foot, and Mouth DiseaseHand, Foot, and Mouth Disease• Although HFM is most

often associated with Coxsackievirus A16, the process does occur with other enterovirus strains (enterovirus 71 & others). A child will develop immunity to an individual strain after an illness but be susceptible to other unrelated strains,.

Dr.T.V.Rao MD 23

Myocarditis can be a serious diseaseMyocarditis can be a serious disease

• Group B Coxsackievirus tend to infect the heart, pleura, pancreas, and liver, causing Pleurodynia, myocarditis, pericarditis, and hepatitis

Dr.T.V.Rao MD 24

Coxsackie B3 - MyocarditisCoxsackie B3 - Myocarditis• Coxsackie B3 has been

found to be one of the main causes of certain debilitating or life-threatening diseases, such as viral myocarditis.

• In about 20% of the cases, there can be progressive disease or recurrence of symptoms; the heart damage can be extensive, causing arrhythmias, weakened left ventricular functions

Dr.T.V.Rao MD 25

Born Holm disease present with…Born Holm disease present with…• Pain on inspiration is similar

to Pleuritic pain and pulmonary embolism may be suspected.

• The muscles are locally tender.

• There will be no haemoptysis. • There may be a slight

sensation of dyspnoea or pain on breathing

• Born Holm word is a place where the disease is identified.

Dr.T.V.Rao MD 26

Difficult to Diagnose ?• Many infections are caused by Coxsackie viruses,

most of which are never diagnosed precisely.• Coxsackie type A usually is associated with

surface rashes (exanthemas) while type B typically causes internal symptoms (Pleurodynia, myocarditis) but both can also cause paralytic disease or mild respiratory tract infection. The latter can be caused by several Coxsackie virus types and by Echoviruses and the symptoms are much like a rhinovirus infection

Dr.T.V.Rao MD 27

Emerging Diagnostic Methods• All the Conjunctival swabs from Coxsackievirus

A24 variant related outbreak and the 41 Coxsackievirus A24 variant strains were tested positive by the RT-PCR assay within 4 h. This novel single-tube real-time RT-PCR assay is sensitive and specific, and consists in a reliable and faster alternative to the viral culture for recent and future acute haemorrhagic conjunctivitis outbreaks caused by Coxsackievirus A24 variant.

Dr.T.V.Rao MD 28

Is Coxsackie Contagious?• VERY contagious• Passed on by:

– Unwashed hands– Surfaced

contaminated by feces

– Sneezes or coughs

Dr.T.V.Rao MD 29

To prevent spread into society

• Children who feel ill or have a fever should be excluded from group settings until the fever is gone and the child feels well. Thorough hand washing and care with diaper changing practices is important.

Dr.T.V.Rao MD 30

Treatment and Prevention

• Treatment usually consists of simple analgesia for sore throat/aches, adequate fluid intake, and rest

There is no vaccine against the Coxsackie's virus

Dr.T.V.Rao MD 31

FDA-approved specific therapyFDA-approved specific therapy• While there is no FDA-

approved specific therapy for Coxsackievirus infection, a recent study demonstrated that fluoxetine (marketed as Prozac in the US) appears to inhibit replication of viral RNA in vitro.

Dr.T.V.Rao MD 32

Newer treatments ?• Specific antiviral therapy

such as Pleconaril shows promise in the treatment of meningitis and other life threatening infections due to enterovirus.

• However, the safety or efficacy of this drug to be considered with more tails

Dr.T.V.Rao MD 33

Prevention• Coxsackie virus is

transmitted by contamination with feces, which means you can catch the virus by touching your mouth or eating without thoroughly washing your hands. Good hand wash reduces the spread of infection in society

Dr.T.V.Rao MD 34

• Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in

the Developing World• Email

• doctortvrao@gmail.comdoctortvrao@gmail.com

Dr.T.V.Rao MD 35