What Is Coxsackievirus?

Have you ever heard of Coxsackievirus? Have you ever been unwell with flu-like symptoms during the warmer months of the year? The likely reason for that is a Coxsackievirus infection. Although more frequent in children, these viruses are quite common worldwide and can cause a range of manifestations from flu-like symptoms to skin rashes or gastrointestinal discomfort.

Overview

The Coxsackieviruses were first identified in the 1940s by analysing the faeces of paralysed children living in Coxsackie in New York.¹ They belong to the enterovirus genus and  picornavirus family, which includes more known viruses such as polioviruses. Coxsackieviruses can be distinguished into two subgroups, A and B. Nowadays, there are 23 identified strains of Coxsackievirus A and 6 strains of Coxsackievirus B. They are non-enveloped viruses that carry their genes in the form of RNA, as opposed to DNA like humans.^2,3,4

But how are these viruses transmitted? Coxsackieviruses are very contagious and can be readily transmitted to others via the oral-faecal or respiratory routes, as well as through oral secretions and fluids such as saliva or nasal mucus from infected individuals if viruses are present in the throat. Transmission by aerosols is also possible in the presence of pulmonary disease. Touching objects and surfaces that came into contact with infected humans such as dirty hands, foods or polluted water is also how the virus commonly spreads. Therefore, encouraging hygiene measures such as frequent hand washing is essential to prevent the transmission.^2,3

These viruses follow the same routes as polioviruses in the sense that they multiplicate in the throat and small intestine, then get absorbed into the bloodstream or lymphatic system to reach the target organs. The first week of Coxsackievirus infection is the most contagious, while the second week of the sickness is rarely transmittable. The virus incubation period, the time elapsed from exposure to first symptoms,  ranges from 3 to 6 days.²

With the COVID-19 pandemic, the implemented measures to slow down the SARS-CoV2 transmission and to contain the outbreak to manageable levels, such as the quarantine of those exposed to the virus, the travel restrictions or cancellation of mass gatherings had a positive effect on the reduction in the prevalence of a range of illnesses, amongst them some caused by Coxsackieviruses.⁵

Although Coxsackieviruses is very easily spread, children can be continuing to go to schools and daycare as long as they have very mild symptoms and:

• Feel well enough to be involved in classroom activities
• Don’t have a fever
• Don’t drool uncontrollably if they have mouth sores

However, in some situations, the local health agency may require children with hand, foot and mouth disease (HFMD) to stay at home to manage an outbreak.

Coxsackievirus infection is typically identified clinically by doctors based on the patient's symptoms. In more severe situations, laboratory testing might be necessary to make identification easier. Vesicle fluid, throat or buccal swabs, or even faeces are the ideal samples to test for confirmation using RT-PCR assays. However, in European countries, in situations of respiratory illness, it is impossible to diagnose an infection caused by Coxsackievirus as the RT-PCR tests do not distinguish the enterovirus from the rhinovirus (that belongs to the same family of picornavirus).

Other tests that may be required to determine an infection caused by a Coxsackievirus are the viral culture, although this method can be very time-consuming or the serological test, for when there is a suspect on the variant causing the infection.¹

Causes of coxsackievirus

Infections caused by Coxsackievirus are linked to a variety of illnesses and although they are most common in children they infect many adults worldwide too.  The climate has a major influence on the distribution of the cases as the Coxsackieviruses are endemic in tropical locations and more common in temperate climates throughout the summer-autumn season. In these months, vigilance increases for the disease rates and possible new recombinant viruses.

The majority of Coxsackievirus infections occur in children under the age of 10 and often have very mild symptomsMore serious ilness frequently affects pregnant women, new-born or premature babies, people who are undernourished or suffering from cold stress, and people who have other underlying medical disorders like immunodeficiency.

Signs and symptoms of coxsackievirus

Similarly, to other enteroviruses, Coxsackievirus infections typically result in asymptomatic infections, but they can also produce a wide range of clinical signs, including fever, rash, respiratory infections, and flu-like symptoms with muscle aches and gastrointestinal discomfort.  Some of the most common illnesses caused by Coxsackieviruses are Hand, foot and mouth disease (HFMD),  linked to the development of rashes such as mouth ulcers, and Bornholm disease (also known as pleurodynia), which causes acute pains in the chest and sides.Both diseases are caused by Coxsackieviruses type A. 

The majority of group B Coxsackieviruses induce muscular injury or neuronal degeneration and are more frequently responsible for neonatal systemic disease. Moreover, Coxsackievirus B is the major cause of viral myocarditis, especially in neonates and infants.¹

Alongside with enterovirus A71 the Coxsackievirus A16 is the most important virus causing HFMD epidemics. Other variants such as Coxsackievirus A6 and Coxsackievirus A10 have also been reported to cause HFMD being responsible for the increase in cases in the last five to six years. This disease has been very common in children in the Asia-Pacific region, although there were some reported cases in Europe and North America in more recent years.

HFMD is characterized by:

• Feeling unwell
• Fever
• Sore throat
• Rash presenting as eruptions surrounded by a red hal on the palms of the hands and soles of the feet
• Mouth sores

As for the Bornholm illness, it is most common in adults and is characterized by chest aches that get worse as you breathe. These chest aches, which can last for days up to 2 weeks, can be mistaken for myocardial infarction (heart attack). Usually in these situations fever or stomachache frequently accompany these symptoms.

Other more severe symptoms can include:

• Viral meningitis accompanied by fever, headaches, stiff neck, nausea and vomiting
• Encephalitis, which can present with seizures and confusion and in the most severe cases can be fatal
• Myocarditis, that presents with shortness of breath, irregular heartbeat and chest pain
• Pancreatitis, where a severe pancreatitis due to Coxsackievirus B can lead to the development of type one diabetes
•  Pneumonia
•  Hepatitis
•  Systemic neonatal illness^1,

Management and treatment for coxsackievirus

Coxsackievirus infections are generally self-limited, meaning that they resolve spontaneously and  there is no suggested treatment for them. Doctors may, however, provide supportive care for symptomatic infections to relieve some of the symptoms. Paracetamol or ibuprofen are some  medications that may be prescribed. As for the antibiotics, they are not the right medication to treat viral infections and so will not be the doctor’s choice.

There are also some other things we can do to help relieve symptoms, like making sure to be hydrated, avoid acidic drinks or spicy food. It is also crucial to remember that while infected with the Coxsackievirus, which is highly contagious, hygiene practices, such as frequent hand washing, are critical to preventing the virus from spreading.

FAQs

How is coxsackievirus diagnosed?

Coxsackievirus is identified clinically according to the symptoms presented more severe situations RT-PCR, viral cultures, or serological tests can be used to ease identification.

Can coxsackievirus be prevented?

Coxsackievirus infection can be prevented by avoiding:

• Contact with  infected people especially if they  cough or sneeze, releasing respiratory droplets
• Touching objects or surfaces that can have the virus. This includes touching an infected person’s faeces (for example by changing diapers) followed by touching your eyes, nose, or mouth

Moreover, good hygiene practices such as frequent hand washing are key to reducing the risk of becoming infected with Coxsackievirus.

Who is at risk of coxsackievirus infection?

Although anyone can develop symptoms caused by a Coxsackievirus infection, the people more at risk of being infected are children underl 10 years of age.

How common is coxsackievirus?

Coxsackievirus is one of the most prevalent viruses worldwide, however, most of the time infections are asymptomatic or with mild symptoms. 

Is coxsackievirus contagious?

The Coxsackievirus is very contagious as it can be spread through secretions such as saliva, respiratory droplets, mucus from infected people, through their faeces or even from contaminated objects and surfaces.

How long does coxsackievirus infection last?

In symptomatic cases, the Coxsackievirus infection can last from a few days to a few weeks, dependingon the severity of the infection. However, most people infected are asymptomatic and do even not know that they are infected. 

When should I see a doctor?

The infection by Coxsackievirus is self-limited, meaning it will resolve itself without medication and there is no specific treatment available. However, doctors can prescribe medicine to manage the symptoms caused by the Coxsackievirus infection.

Summary

The Coxsackievirus is a virus that belongs to the genus of the enteroviruses and the family of picornaviruses and can be distinguished in two different subgroups. They are prevalent worldwide and very contagious. Most of the time the infections are asymptomatic and most common in children. When symptomatic, an infection frequently presents as hand, foot and mouth disease. In these situations, the symptoms are fever, sore throat, rash or spots on the mouth, the hands and feet. More severe cases can lead up to meningitis, myocarditis, pancreatitis, pneumonia, or systemic neonatal illness. The diagnosis of Coxsackievirus is performed by doctors based on the symptoms and the treatment is to manage and relieve symptoms as there is no specfic medication to target the virus.