Which physical findings are characteristic of enterovirus infection?

Updated: Mar 17, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Physical examination findings in enteroviral disease vary greatly depending on the type of illness and etiologic agent, as follows:

  • Nonspecific febrile illness: Physical findings are those of general viral illness; mild pharyngeal erythema or conjunctivitis may be present.

  • Pleurodynia: Paroxysmal chest pain is characteristic, has no prodrome, and begins with an abrupt onset of spasmodic pain, typically over the lower part of the rib cage or the upper abdominal region. Fever often occurs within one hour of the onset of pain and subsides as the pain recedes. During paroxysms, respirations are rapid and shallow. The pain is reproducible, and patients appear healthy between paroxysms of pain. Auscultation may reveal a pleural friction rub.

  • Myopericarditis: The most common symptoms are dyspnea, chest pain, fever, and malaise. [4] Pain in the precordial area maybe sharp or dull and is often exacerbated by the recumbency position. A pericardial friction rub is transient, if present. Signs of congestive heart failure are present in 20% of cases. [5]

  • AHC: The hallmark physical findings include ocular erythema and subconjunctival hemorrhage, which seems to be more profuse in young patients. [6] Palpebral edema, chemosis, and ocular discharge may also be noted. Preauricular lymphadenopathy is an associated finding in AHC.

  • Aseptic meningitis: Meningeal signs (nuchal rigidity, bulging fontanelles in infants) may be present, along with a positive Kernig and/or Brudzinski sign. Some patients develop a rash. Adults may experience a more prolonged period of headache and fever than children. [58] Approximately 5%-10% of infants with aseptic meningitis experience complications such as febrile seizures, complex seizures, lethargy, coma, and movement disorders early in the course. [7]

  • Encephalitis: Manifestations range from lethargy, drowsiness, and personality change to seizures, paresis, coma, motor seizures, hemichorea, and acute cerebellar ataxia. [8]

  • Herpangina: Examination of the oral mucosa reveals punctate macular lesions that evolve into vesicles and eventually ulcerate. The most common site of involvement is the anterior tonsillar pillar and soft palate (mimics pharyngitis or tonsillitis). The lesions are tender and subside within one week.

  • HFMD: Vesicular lesions develop on the hands and feet and in the oral cavity. Hands are involved more commonly than feet. The skin lesions consist of mixed papules. Clear vesicles appear gray and are surrounded by erythematous rings. Lesions are tender and resemble those of herpes simplex or varicella zoster infection. They resolve in approximately one week.

  • The coxsackievirus A6 (CVA6)–associated North American enterovirus outbreak of 2011-2012 was evaluated. [59] Atypical HFMD was noted as a vesiculobullous and erosive eruption, with 61% of patients having the rash involving more than 10% body surface area in a perioral, extremity, and truncal distribution in addition to palms, soles, and buttocks. In half the patients, there was an accentuation in areas of eczematous dermatitis. Other morphologic patterns included those of Gianotti-Crosti disease in 37% and petechial/purpuric eruptions in 17%.

  • Poliomyelitis

    • Nonparalytic polio: Signs of meningeal irritation are present, and patients may have positive Kernig and Brudzinski signs. In infants, the head drop sign can be elicited.

    • Paralytic polio: In early-stage disease, reflexes are normally active. A change in the character of reflexes precedes paralysis by 12-24 hours. Superficial reflexes are the first to decrease, followed in 8-24 hours by loss of deep tendon reflexes. The resultant paralysis is flaccid and characteristically asymmetric in distribution. Proximal limb muscles are involved more than distal muscles. The lower extremities are affected more commonly than the upper extremities.

  • Orchitis: In some remote cases, the presentation of coxsackievirus B infection clinically resembles mumps orchitis.

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