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I want to switch over to the enteroviruses. Infections with enteroviruses are exceedingly common. Every summer literally every child has at least one enterovirus infection. These are usually quite trivial but the fact is that fevers in the summertime are invariably due to enteroviruses. Enteroviruses are not big viruses. They are small, 28 millimicrons in diameter. We now know that antibody to surface proteins is protective and so conceivably if new strains develop, vaccines like polio vaccines can be developed. Enteroviruses are polios 1,2,3. Coxsackie viruses group A, coxsackie group B and these were differentiated, and echoviruses, were differentiated on how they behaved in tissue culture or suckling mice. But then many of these, for example coxsackie A, produced a flaccid paralysis in mice, but many of them like coxsackie A-9 grows very well in tissue culture. So later on they were just called enteroviruses, of which there are 68-71; 72 was hepatitis A but that’s been removed from the enterovirus category. The enteroviruses are spread person-to-person. There is no animal reservoir but they can be spread by flies. Flies don’t get infected but they will pick up enteroviruses from sewage and things like that.
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The worldwide distribution; in temperate climates they occur in summer and fall. In the tropics they have caused disease throughout the whole year. This is the pathogenesis of infection. Infection is usually through the mouth, either oral or upper respiratory. Then local infection and then direct spread to tonsils and lymph nodes, Peyer’s patches and mesenteric lymph nodes. Following this there is a minor viremia which multiple organs get seeded and congenital infection starts here. You get multiple infections and then you get major viremia, which is associated with symptoms. For example polio, there has always been a theory that didn’t get a hit now but gets a hit with secondary viremia. I’m not sure that that’s true but frequently you see … but I think it’s more immunologic. Then the infection clears by itself relatively rapidly and there is no persistent infection except for what I showed you with coxsackie A-16 and exanthem.
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There are a lot of clinical … every organ can be involved and I just want to go through some of this in the time remaining. The first thing is asymptomatic infection. Of course with polio we were aware that less than 5% – somewhere around 2% – of infections led to asymptomatic meningitis or paralytic polio. The majority were frequently called asymptomatic but it was better to say unrecognized because most of these had non-specific febrile illness. That is the major manifestation of enterovirus infections in the summertime. Roughly a three-day period where the child may not be exactly with it, and may vomit once or have one loose stool, but just has fever. In your handout I’ve given you some frequencies of various things, which I’m not going to talk about, but they are in the handout. Enteroviruses, except for coxsackie A-21, rarely cause the common cold which we talked about. But pharyngitis is a major manifestation of most enteroviruses and can’t be differentiated from streptococcal disease clinically. Herpangina we talked about. This is a form of herpangina which was described and really hasn’t been noticed since. Stomatitis; I showed you pictures of that with hand-foot-and-mouth disease. Parotitis today, with the control of mumps, that enterovirus is a leading cause of parotitis in children except for children with exposure to mice. Bronchitis, bronchiolitis, pneumonia, are generally picked up in serologic surveys and are not particularly important.