Detailed Awareness Campaign On Enteroviral Infection

Enterovirus infections (ECНO and Coxsackie’s infections) a group of an acute diseases caused by ECНO and Coxsackie’s enteroviruses, that  are characterized by the variety of clinical displays from the mild fever and simple carrying of virus to protracted meningoencephalitis, myocarditis, myalgia and other.

Etiology: ECНO and Coxsackie’s enteroviruses.

Enteroviruses

Epidemiology:

§        the source of infection is patients and viral carriers;

§        the mechanism of transmission is droplet, fecal-oral, transpacental;

§        receptivity is high, especially in age 3-10 years.

Pathogenesis

1.     Inoculation and replication of virus in an epithelium and lymphoid formations of the intestine and upper respiratory tract.

2.     Viremia.

3.     Damage of organs and systems.

Classification

A form: -1. typical forms:

Isolated forms: 

·        serous meningitis;

·        epidemic myalgia;

·        herpangina;

·        paralytic form;

·        ECНO and Coxsackie’s fever;

·        ECНO and Coxsackie’s exanthema;

·        gastroenteritis;

·        myocarditis;

·        encephalomyocarditis of the new-borns;

·        enteroviral uveitis;

·        orchitis, epididimitis.

·        Combined forms;

2. atypical (effaced, subclinical).

Severity:    

·        mild degree;

·               moderate degree;

·               severe degree.

Course:   

·        smooth;

·        uneven.

Diagnostic criteria, common for all forms of Enterovirus infection

• Latent period lasts 2-10 days.

• Acute beginning from toxic syndrome (high body temperature 39-40 °C, headache, malaise, fatigue, repeated vomiting, decreased appetite), abdominal pain, catarrhal syndrome.

• Hyperemia of overhead half of trunk skin, neck, and face.

• Injection of sclera vessels.

• Hyperemia, graininess of soft palate, and back pharyngeal wall.

• Neck catarrhal lymphadenitis, or polyadenitis, may be hepato-splenomegaly.

Serous meningitis – one of the most often forms

• Often in children of 5-9 years.

• Sporadic or flashes in children collectives.

• High temperature (39-40 °C) for 1-10 days.

• Intensive headache, nausea, vomiting, seizures and hallucinations.

• Loss of appetite, abdominal pain.

• Positive meningeal signs from the desease beginning (nuchal rigidity, Brudzinski’s and Kernig’s signs, anterior fontanel bulging, decreased abdominal skin rephlexes).

• All this signs are instabile, disappear when temperature becomes normal.

• CSF: moderate polymorphonuclear-lymphocyte cytosis in the beginning, later – lymphocyte cytosis, protein is normal (Pandy’s test is negative), shugar is normal or slightly decreased.

• CSF normalization in 3-4 weeks.

• Possible relapses (on 15-30 days) – fever, headache, vomiting.

• In recovery period – asthenia, CSF hypertension.

Epidemic myalgia

• Acute muscular pain in the chest, upper part of abdomen, back, limbs.

• Painful superficial breathing.

• Orthopnoe position of the patient (in case of pain attack).

• Duration is 3-14 days.

• May be relapses.

• May be combination with other forms.

Paralytic form

• More often in children of 4-8 years.

• Normal temperature.

• Languid monoparesis of limbs (muscular weakness of buttocks, thighs, mimic

muscles, impaired gait).

• Decresed muscular tonus and tendon rephlexes.

• Rapid normalization of impaired muscles function.

• CSF is normal.

Herpangina (vericulous pharyngitis)

• Exept common criteria – pharyngeal hyperemia with small papules (1-2 mm) on palatal arch, tonsils, uvula, back pharyngeal wall which turn for vesicules very fast. Small vesicules disappear, larger – turns for aphthae with fibrinous center and red circumpherence

• Submandibular lymphnodes enlargement

• Recovery in 4-7 days

Enteroviral fever ("small disease")

• The most often form in preschoolers.

• Three days fever.

• Mild headache.

• Sometimes nausea, vomiting and abdominal pain.

• Conjunctives and pharynx are hyperemied.

• Lymphadenopathy, mild hepato-, splenomegaly.

• Duration is 2-3 weeks.

Epidemic exanthema

• Is often in schoolchildren.

• Typical common toxic and catarrhal signs.

• Rashes appear in 1-2 days simultaneously on the face, chest and limbs (pinkish maculous-papulous or erythematous, descreate).

• Maculous enanthema on the soft palate.

• Rashes disappear in 2-4 days, sometimes with pigmentation, without desquamation.

Enteroviral diarrhea

• Is often in infants and toddlers.

• Moderate fever (39-40 °C).

• Abdominal pain, vomiting.

• Stools are watery, sometimes with mucus, green admixtures.

• Metheorism may be present.

Respiratory-catarrhal form ("summer flu")

• Is characterized by common signs, typical for enteroviral infection

• Short (for 1-5 days) course, mild severity, without complications

• Dry cough and rhinitis

Encephalomyocarditis and myocarditis in newborns

• Is caused by Coxsackie B viruses.

• Is transmitted enterally or trasplacentary.

• Typical acute beginning from fever (39-40 °C).

• Dyspepsia (vomiting, diarrhea).

• Intoxication (malaise, decreased appetite, sleepiness).

• Dilation of cardiac borders, systolic murmur, tachycardia.

• Rapid development of cardiac insufficiency (dyspnea, hepatomegaly).

• Encephalitis with tonic-clonic seizures, consciousness violation.

• In CSF: lymphocyte pleocytosis, protein is elevated.

• On ECG – changes, typical for myocarditis (low voltage, negative T-vave, QRSdilation,

ST-interval depression, hypoxic P-vave).

• Letal exit in 1-2 days.

 

Rash in Enterovirus infection

Enterovirus herpangina

Laboratory diagnostics

• Virological investigation of nasopharyngeal smears, feces, CSF.

• Serological investigations (CBR with paired sera), titre enlargement 4 times and more.

• CBC: leucopenia, with neutrophylosis, lymphopenia, eosynophylia, elevated ESR.

• CSF: moderate neuthrophyl-lymphocyte, than lymphocyte pleocytosis, normal or slight elevated protein, Pandy’s test is negative, sugar and chlorides are normal or slight decreased.

Diagnosis example: Enterovirus infection, typical, isolated form (epidemic myalgia), moderate degree, smooth course

Differential diagnostics with: URT viral infections, typhoid, paratyphoid, tubercular meningitis, acute appendicitis, cholecystitis, pancreatitis, rubella, yersiniosis, medicinal rashes, herpetic infection, acute intestinal infections.

Differential diagnostics of poliomyelitis with similar forms of enteroviral infection

Signs	Poliomyelitis	Poliomyelitis  like forms of enteroviral infection
Latent period	5-35 days	2-10 days
Toxic syndrome	severe	Mild or moderate
fever	high	moderate
Catarrhal signs	mild	typical (herpangina)
Preparalytic period duration	2-3 days	5-7 days
Skin rashes	absent	Often present
paralysis	peripheral paralysis, stable	peripheral paresis, usually disappears
the tendon reflexes	absent	Decreased or normal
Muscular atrophy	typical	Rare, some muscles
Renewal of function	Less damaged motoneurons in a year	Practically complete in 3-4 wks
CSFchanges	As in serous meningitis	Not typical
Virological studies	Poliovirus	Coxackie A, ЕСНО

Treatment:

• Bed regimen in acute period.

• Etiologic therapy: specific therapy is absent.

• Control of fever.

• NSAIDs for pain relieve.

• Physiotherapy (in case of epidemic myalgia or paralytic form).

Meningitis treatment

Base therapy:

• Bed regimen till body temperature normalization, disappearance of general cerebral and considerable improvement of focal neurological signs, not less than 14-16 days;

• A diet (before stable vital functions is due to adequate parenteral infusion therapy);

• Brest feeding or bottle feeding by adopted formulas for infants, in the first day 1/2-1/3 of average volume with a next increase to the complete volume during 2 -3rd days;

• A milk vegetable diet (№5) is appointed for preschoolers or school children, 5-6 times per day with the next passing to the diet №2 whether №15 (depending the age) in the recovery period;

• Oral fluids intake corresponds to age norms (with including the IV fluids);

• Antibacterial therapy: for infants at presence of concomitant bacterial infection, chronic infection, inflammatory changes in the CBC (by the broadspectrum antibiotic in average therapeutic doses, a short course).

Pathogenetic therapy:

• Glucocrticoids 3-5 mg/kg (by prednisolon), course not more than 10 days;

• Vascular medicine (penthoxyphyllin, nicergolin and others like that);

• In posthypoxia period – nootrops, vitamins group B;

• In case of CSF hypertension – dehydration by 25 % MgSO4 IM, lasix 1-3 mg/kg IV or IM, acethazolamid orally

• In case of seizures – Anticonvulsant therapy: benzodiasepins (seduxenum, sibasonum) 0.3-0.5 mg/kg IV, if they are ineffective – 1 % hexenalum or thiopenthalum sodii in 3-5 mg/kg IV. Dehydration therapy: lasix 2-3 mg/kg IM or IV.

Encephalomyocarditis treatment:

·        dehydration (lasix 1-3 mg/kg, mannit, mannitol 1-1.5 g/kg); in case of seizures (seduxen 0.3 mg/kg,  droperidol 0.25% 0.05-0.1 ml/kg);

·        detoxication (rheosorbilact, albumen 5-15 ml/kg, 5% glucose);

·        glucocorticoids  (prednisolone 1-3 mg/kg,);

·        trental 0.2-0.5  ml/kg;

·        noothrope facilities (noothropil 50 mg/kg, stugeron, cavinton, aminalon);

·        cardiac glycosides (strophantyn, corglycon up to 6 month 0.05 ml, 6-12 months 0.1 ml, farther 0.012  ml/kg);

·        cardiotonic medicine (mildronat, ryboxin)

         Bacterial complications: antibiotics (penicillins, cefalosporins).

Prophylaxis:

1.     Early exposure and isolation of patients up to 10 days, patients with serous meningitisare discharged from hospital not early than 21 days, clinicaly healthy and after normalizationof CSF.

2.     Interferon (in nostrils) 5 drops 3-4 times per day, for 10-15 days.

3.     Human immune globulin 0.2 ml/kg IM.

4.     Quaranteen to contacts for 14 days.

5.     Current disinfection, hygienic regimen, respiratory mask wearing.

6.     Ultraviolet insolation.

References:

Main:

1.     Current therapy in pediatric infectious diseases – 2 edited by John D. Nelson, M. D. – B.C. Decker  inc. Toronto, Philadelphia, 1988, - P. 134-138, 285.

2.     Ambulatory pediatric care (edited by Robert A. Derchewitz; - 2 nd ed. – Lippincot – Raven, 1992. – P. 570-574; 255.          

3.     Principles and Practice of Pediatric Infectious Diseases. / Edited by Saran S. Long, Larry K. Pickering, Charles G. Prober, Philadelphia, Pa: Churchill Livingstone; 1997. – 1921 p.

Additional:

1.     Textbook of Pediatric Nursing.  Dorothy R. Marlow; R. N., Ed. D. –London, 1989.-661p.

2.     Pediatrics ( 2^nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.