EnterovirusesEnteroviruses

Dr M.KarimiDr M.Karimi

Genera of PicornavirusesGenera of Picornaviruses

Enterovirus:Enterovirus: Polio,Coxsackie A and BPolio,Coxsackie A and B

Echo,Other enteroviruses Echo,Other enteroviruses Rhinovirus Rhinovirus CardiovirusCardiovirus HepatovirusHepatovirus Aphthovirus Aphthovirus OthersOthers

With only six polio endemic countries left in the world, polio With only six polio endemic countries left in the world, polio transmission could be stopped by end 2005.  The world could transmission could be stopped by end 2005.  The world could

then be certified polio-free by end-2008.then be certified polio-free by end-2008.

EnterovirusesEnteroviruses

RNA Viruses Polio RNA Viruses Polio

Include some group of Include some group of

CoxackievirusesCoxackieviruses

Polio viruses Polio viruses

Picornaviruses EchovirusesPicornaviruses Echoviruses

HerpanginaHerpangina

Clinical manifestation of Enterovirus Clinical manifestation of Enterovirus InfectionsInfections

Aseptic meningitisAseptic meningitis Nonspecific febrile Nonspecific febrile

illnessillness ColdsColds ConjunctivitisConjunctivitis PharyngitisPharyngitis HerpanginaHerpangina HepatitisHepatitis

ExanthemsExanthems EncephalitisEncephalitis Paralytic polioParalytic polio VomitingVomiting DiarrheaDiarrhea PericarditisPericarditis MyocarditisMyocarditis Hand-foot-mouth Hand-foot-mouth

syndromesyndrome

EpidemiologyEpidemiology

Transmission from person to person:Transmission from person to person:

Fecal-OralFecal-Oral

RespiratoryRespiratory Peak incidence : Summer & FallPeak incidence : Summer & Fall Male =FemaleMale =Female Age: Young childrenAge: Young children Incubation period: 3-6 DaysIncubation period: 3-6 Days

PathogenesisPathogenesis URI InfectionURI Infection Regional lymph nodes involvementRegional lymph nodes involvement Low-Grade viremia Low-Grade viremia

((Heart,Skin,Pericardium ,Lung..)Heart,Skin,Pericardium ,Lung..)

Clinical illness & Major viremiaClinical illness & Major viremia Antibody appearance on 7Antibody appearance on 7thth day day GI ReplicationGI Replication

PathophysiologyPathophysiology

1.1. Polio→Motor neurons (Polio→Motor neurons (Pathogonomic Pathogonomic

findingfinding))

2.2. Coxackieviruses → Herpangina Coxackieviruses → Herpangina

→ → Hand foot-mouth Hand foot-mouth

→ → MyocarditisMyocarditis Meningoencephalitis,Adrenal glands,Pancrease,Liver,PleuraMeningoencephalitis,Adrenal glands,Pancrease,Liver,Pleura

3. Echovirus → Hepatic necrosis3. Echovirus → Hepatic necrosis

Clinical manifestation Clinical manifestation PoliovirusesPolioviruses

(1)(1)

• Asymptomatic infectionAsymptomatic infection(95%)(95%)

• Abortive formAbortive form:Fever, Headache, :Fever, Headache, Malaise,Anorexia ,Nausea,Vomiting,PharMalaise,Anorexia ,Nausea,Vomiting,Pharyngitis,Abdominal painyngitis,Abdominal pain

• Nonparalytic formNonparalytic form:Abortive form :Abortive form symptoms, Menengeal sign, Decrease symptoms, Menengeal sign, Decrease deep and superficial tendon reflexesdeep and superficial tendon reflexes,,

Clinical manifestation Clinical manifestation PoliovirusesPolioviruses(2)(2)

• Paralytic form:Paralytic form:Similar to nonparalytic Similar to nonparalytic form+Muscle weakness,BP form+Muscle weakness,BP changes,Respiratory and cardiac arrhythmia, changes,Respiratory and cardiac arrhythmia, Weakness,Falccid Paralysis(Typically Weakness,Falccid Paralysis(Typically asymetric proximal muscle involvement)asymetric proximal muscle involvement)

• Spinal formSpinal form: Axial and extremity muscle : Axial and extremity muscle weakness weakness

• Bulbar formBulbar form: Cranial nerve involvement : Cranial nerve involvement (Dysphagia)(Dysphagia)

• Encephalitic formEncephalitic form: : irritability,disorientation ,drowsiness,tremorirritability,disorientation ,drowsiness,tremor

PoliovirusesPolioviruses

Prodrome: Headache,Malaise,Menengeal Prodrome: Headache,Malaise,Menengeal sign,CSF pleocytosissign,CSF pleocytosis

Sever myalgia, Sever myalgia, Meningismus,Weakness,Flaccid paralysisMeningismus,Weakness,Flaccid paralysis

Asymetric distributionAsymetric distribution Proximal muscles involve more than distal Proximal muscles involve more than distal

musclesmuscles Sensory function remains intactSensory function remains intact

Respiratory Insufficiency Respiratory Insufficiency symptomssymptoms

AnxietyAnxiety TachypneaTachypnea Respiratory distress symptomsRespiratory distress symptoms Decrease coughDecrease cough Paradoxic abdominal movementParadoxic abdominal movement Immobility of intercostal spacesImmobility of intercostal spaces Arm&Deltoid weaknessArm&Deltoid weakness

Bulbar PolioBulbar Polio

Palatal & Pharyngeal weakness Palatal & Pharyngeal weakness (nasal voice)(nasal voice)

Pooling of salivaPooling of saliva Poor coughPoor cough Nasal regurgitation of salivaNasal regurgitation of saliva Deviation of palate,uvula,tongueDeviation of palate,uvula,tongue Hoarseness , AphoniaHoarseness , Aphonia BP ChangesBP Changes

Differential diagnosisDifferential diagnosis

Guillain-Barre syndromGuillain-Barre syndrom Other viral encephalomyelitisOther viral encephalomyelitis Tick paralysisTick paralysis CNS TumorCNS Tumor TraumaTrauma Vaccine associated paralytic polioVaccine associated paralytic polio

PrognosisPrognosis Determined during 1 month after infectionDetermined during 1 month after infection Some degree of permanent damageSome degree of permanent damage Bulbar paralysis generally recover completelyBulbar paralysis generally recover completely

TYPICAL CONTRACTURESTYPICAL CONTRACTURES

IN POLIOIN POLIO

Nonpolio Enteroviral Nonpolio Enteroviral InfectionInfection

Asymptomatic:Asymptomatic: (Less than 50%) (Less than 50%) Nonspecific febrile illness:(Nonspecific febrile illness:(Lasts 3 days)Lasts 3 days)

(Most common manifestation of all types of entroviral infections)(Most common manifestation of all types of entroviral infections)

Fever, Malaise, Headache, Pharyngitis, Fever, Malaise, Headache, Pharyngitis,

Myalgia, GI symptoms in neonateMyalgia, GI symptoms in neonate

Respiratory tractRespiratory tract illness:illness:

Conjunctivitis, Herpangina,Pharyngitis,Stomatitis, Conjunctivitis, Herpangina,Pharyngitis,Stomatitis, Parotitis ,Croup,Bronchitis, Parotitis ,Croup,Bronchitis, Pneumonia,Pleurodynia,Pneumonia,Pleurodynia,

Herpangina:Herpangina:Fever, Oral ulcers and vesiclesFever, Oral ulcers and vesicles

Duration 3-6 daysDuration 3-6 days

PleurodyniaPleurodynia

Acute febrile illnessAcute febrile illness Intense pleuritic painIntense pleuritic pain Upper abdominal muscular painUpper abdominal muscular pain CXR: NormalCXR: Normal WBC: Normal or elevated myeloid WBC: Normal or elevated myeloid

cellcell

Nonpolio Enteroviral Nonpolio Enteroviral InfectionInfection

Gasterointestinal manifestation:Gasterointestinal manifestation:Vomiting,Non bloody diarrhea,Abdominal pain, Vomiting,Non bloody diarrhea,Abdominal pain,

PseudoappendicitisPseudoappendicitis Acute hemorrhagic conjunctivitis:Acute hemorrhagic conjunctivitis:Eye pain, Photophobia,Blurred Eye pain, Photophobia,Blurred

vision,Lacrimation,Erythma, Conjunctivitisvision,Lacrimation,Erythma, Conjunctivitis Pericarditis&Myocarditis:Pericarditis&Myocarditis:High mortality especially in neonateHigh mortality especially in neonate

Nonpolio Enteroviral Nonpolio Enteroviral InfectionInfection

Hand-foot-mouth Hand-foot-mouth syndromesyndrome::

Small intraoral ulcer, Small intraoral ulcer, Macular or vesicular Macular or vesicular lesion on hands and lesion on hands and feet&buttockfeet&buttock

Hand-foot-mouth Hand-foot-mouth syndromesyndrome::

Nonpolio Enteroviral Nonpolio Enteroviral InfectionInfection

Aseptic meningitis syndromeAseptic meningitis syndrome::Rash,Sore throat,Muscle pain, Sign of meningeal irritationRash,Sore throat,Muscle pain, Sign of meningeal irritationCSF (PMN pleocytosis,High protein,Normal glucose),CSF (PMN pleocytosis,High protein,Normal glucose),

Seasonal Encephalitis:Seasonal Encephalitis:

Paralysis:Paralysis:Acute hemiplegia,Perphral neuritisAcute hemiplegia,Perphral neuritis

Genitourinary: Genitourinary: Orchitis,Epididymitis,Cystitis ,HematuriaOrchitis,Epididymitis,Cystitis ,Hematuria

Myositis&ArthritisMyositis&Arthritis::Dermatomyositis-like syndromeDermatomyositis-like syndrome

Nonpolio Enteroviral Nonpolio Enteroviral InfectionInfection

Neonatal nonspecific febrile illness:Neonatal nonspecific febrile illness:Duration 3-4 days, Fever, Anorexia , Irritability, Mild Duration 3-4 days, Fever, Anorexia , Irritability, Mild

vomiting, Diarrhea, PMN leuckocytosisvomiting, Diarrhea, PMN leuckocytosis

Neonatal myocarditis:Neonatal myocarditis: Fever,Tachycardia,Fever,Tachycardia,Cardiomegaly , ECG changes ,Transient systolic Cardiomegaly , ECG changes ,Transient systolic

murmur ,Shock, Respiratory distressmurmur ,Shock, Respiratory distress

Fulminant encephalomyocarditisFulminant encephalomyocarditis

DiagnosisDiagnosis

Age, Season, Location, ExposureAge, Season, Location, Exposure Clinical manifestationClinical manifestation PCRPCR Culture from sterile sites biopsyCulture from sterile sites biopsy

Treatment:Treatment:

Supportive therapySupportive therapy Pleconaril in Pleconaril in

immunocompetentimmunocompetent No SteroidsNo Steroids

Prevention:Prevention:

OPV/IPVOPV/IPV

Vaccination programVaccination program

At Birth: BCG’ OPV’ Hepatitis B*At Birth: BCG’ OPV’ Hepatitis B* 2 Month: DPT’ OPV’ Hepatitis B2 Month: DPT’ OPV’ Hepatitis B 4 Month: DPT’ OPV4 Month: DPT’ OPV 6 Month: DPT’ OPV’ Hepatitis B6 Month: DPT’ OPV’ Hepatitis B 12 Month: MMR12 Month: MMR 18 Month: DPT’ OPV18 Month: DPT’ OPV 4-6 years old: DPT’ OPV’MMR4-6 years old: DPT’ OPV’MMR 14-16 years old: Td 14-16 years old: Td