1. Enteroviruses Dr M.Karimi

2. Genera of Picornaviruses Enterovirus: Enterovirus: Polio,Coxsackie A and B Echo,Other enteroviruses Polio,Coxsackie A and B Echo,Other enteroviruses Rhinovirus Rhinovirus Cardiovirus Cardiovirus Hepatovirus Hepatovirus Aphthovirus Aphthovirus Others Others

3. With only six polio endemic countries left in the world, polio transmission could be stopped by end 2005. The world could then be certified polio-free by end-2008.

4. Enteroviruses RNA Viruses Polio RNA Viruses Polio Include some group of Include some group of Coxackieviruses Coxackieviruses Polio viruses Polio viruses Picornaviruses Echoviruses Picornaviruses Echoviruses Herpangina Herpangina

5. Clinical manifestation of Enterovirus Infections Aseptic meningitis Aseptic meningitis Nonspecific febrile illness Nonspecific febrile illness Colds Colds Conjunctivitis Conjunctivitis Pharyngitis Pharyngitis Herpangina Herpangina Hepatitis Hepatitis Exanthems Exanthems Encephalitis Encephalitis Paralytic polio Paralytic polio Vomiting Vomiting Diarrhea Diarrhea Pericarditis Pericarditis Myocarditis Myocarditis Hand-foot-mouth syndrome Hand-foot-mouth syndrome

6. Epidemiology Transmission from person to person: Transmission from person to person: Fecal-Oral Fecal-Oral Respiratory Respiratory Peak incidence : Summer & Fall Peak incidence : Summer & Fall Male =Female Male =Female Age: Young children Age: Young children Incubation period: 3-6 Days Incubation period: 3-6 Days

7. Pathogenesis URI Infection URI Infection Regional lymph nodes involvement Regional lymph nodes involvement Low-Grade viremia ( Heart,Skin,Pericardium,Lung..) Low-Grade viremia ( Heart,Skin,Pericardium,Lung..) Clinical illness & Major viremia Clinical illness & Major viremia Antibody appearance on 7 th day Antibody appearance on 7 th day GI Replication GI Replication

9. Pathophysiology 1. Polio → Motor neurons ( Pathogonomic finding ) 2. Coxackieviruses → Herpangina → Hand foot-mouth → Hand foot-mouth → Myocarditis → Myocarditis Meningoencephalitis,Adrenal glands,Pancrease,Liver,Pleura Meningoencephalitis,Adrenal glands,Pancrease,Liver,Pleura 3. Echovirus → Hepatic necrosis

10. Clinical manifestation Polioviruses (1) Asymptomatic infection(95%) Asymptomatic infection(95%) Abortive form:Fever, Headache, Malaise,Anorexia,Nausea,Vomiting,Pharyngitis,Abdominal pain Abortive form:Fever, Headache, Malaise,Anorexia,Nausea,Vomiting,Pharyngitis,Abdominal pain Nonparalytic form:Abortive form symptoms, Menengeal sign, Decrease deep and superficial tendon reflexes, Nonparalytic form:Abortive form symptoms, Menengeal sign, Decrease deep and superficial tendon reflexes,

11. Clinical manifestation Polioviruses (2) Paralytic form:Similar to nonparalytic form+Muscle weakness,BP changes,Respiratory and cardiac arrhythmia, Weakness,Falccid Paralysis(Typically asymetric proximal muscle involvement) Paralytic form:Similar to nonparalytic form+Muscle weakness,BP changes,Respiratory and cardiac arrhythmia, Weakness,Falccid Paralysis(Typically asymetric proximal muscle involvement) Spinal form: Axial and extremity muscle weakness Spinal form: Axial and extremity muscle weakness Bulbar form: Cranial nerve involvement (Dysphagia) Bulbar form: Cranial nerve involvement (Dysphagia) Encephalitic form: irritability,disorientation,drowsiness,tremor Encephalitic form: irritability,disorientation,drowsiness,tremor

13. Polioviruses Prodrome: Headache,Malaise,Menengeal sign,CSF pleocytosis Prodrome: Headache,Malaise,Menengeal sign,CSF pleocytosis Sever myalgia, Meningismus,Weakness,Flaccid paralysis Sever myalgia, Meningismus,Weakness,Flaccid paralysis Asymetric distribution Asymetric distribution Proximal muscles involve more than distal muscles Proximal muscles involve more than distal muscles Sensory function remains intact Sensory function remains intact

15. Respiratory Insufficiency symptoms Anxiety Anxiety Tachypnea Tachypnea Respiratory distress symptoms Respiratory distress symptoms Decrease cough Decrease cough Paradoxic abdominal movement Paradoxic abdominal movement Immobility of intercostal spaces Immobility of intercostal spaces Arm&Deltoid weakness Arm&Deltoid weakness

16. Bulbar Polio Palatal & Pharyngeal weakness (nasal voice) Palatal & Pharyngeal weakness (nasal voice) Pooling of saliva Pooling of saliva Poor cough Poor cough Nasal regurgitation of saliva Nasal regurgitation of saliva Deviation of palate,uvula,tongue Deviation of palate,uvula,tongue Hoarseness, Aphonia Hoarseness, Aphonia BP Changes BP Changes

17. Differential diagnosis Guillain-Barre syndrom Guillain-Barre syndrom Other viral encephalomyelitis Other viral encephalomyelitis Tick paralysis Tick paralysis CNS Tumor CNS Tumor Trauma Trauma Vaccine associated paralytic polio Vaccine associated paralytic polio

18. Prognosis Determined during 1 month after infection Determined during 1 month after infection Some degree of permanent damage Some degree of permanent damage Bulbar paralysis generally recover completely Bulbar paralysis generally recover completely TYPICAL CONTRACTURES TYPICAL CONTRACTURES IN POLIO IN POLIO

19. Nonpolio Enteroviral Infection Asymptomatic: (Less than 50%) Asymptomatic: (Less than 50%) Nonspecific febrile illness:(Lasts 3 days) Nonspecific febrile illness:(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 neonate Myalgia, GI symptoms in neonate Respiratory tract illness: Respiratory tract illness: Conjunctivitis, Herpangina,Pharyngitis,Stomatitis, Parotitis,Croup,Bronchitis, Pneumonia,Pleurodynia, Conjunctivitis, Herpangina,Pharyngitis,Stomatitis, Parotitis,Croup,Bronchitis, Pneumonia,Pleurodynia,

20. Herpangina: Fever, Oral ulcers and vesicles Duration 3-6 days

21. Pleurodynia Acute febrile illness Acute febrile illness Intense pleuritic pain Intense pleuritic pain Upper abdominal muscular pain Upper abdominal muscular pain CXR: Normal CXR: Normal WBC: Normal or elevated myeloid cell WBC: Normal or elevated myeloid cell

22. Nonpolio Enteroviral Infection Gasterointestinal manifestation: Gasterointestinal manifestation: Vomiting,Non bloody diarrhea,Abdominal pain, Pseudoappendicitis Acute hemorrhagic conjunctivitis: Acute hemorrhagic conjunctivitis: Eye pain, Photophobia,Blurred vision,Lacrimation,Erythma, Conjunctivitis Pericarditis&Myocarditis: Pericarditis&Myocarditis: High mortality especially in neonate

23. Nonpolio Enteroviral Infection Hand-foot-mouth syndrome : Hand-foot-mouth syndrome : Small intraoral ulcer, Macular or vesicular lesion on hands and feet&buttock

25. Hand-foot-mouth syndrome :

26. Nonpolio Enteroviral Infection Aseptic meningitis syndrome: Aseptic meningitis syndrome: Rash,Sore throat,Muscle pain, Sign of meningeal irritation CSF (PMN pleocytosis,High protein,Normal glucose), Seasonal Encephalitis: Seasonal Encephalitis: Paralysis: Paralysis: Acute hemiplegia,Perphral neuritis Genitourinary: Genitourinary: Orchitis,Epididymitis,Cystitis,Hematuria Myositis&Arthritis : Myositis&Arthritis : Dermatomyositis-like syndrome

27. Nonpolio Enteroviral Infection Neonatal nonspecific febrile illness: Neonatal nonspecific febrile illness: Duration 3-4 days, Fever, Anorexia, Irritability, Mild vomiting, Diarrhea, PMN leuckocytosis Neonatal myocarditis: Neonatal myocarditis: Fever,Tachycardia, Fever,Tachycardia, Cardiomegaly, ECG changes,Transient systolic murmur,Shock, Respiratory distress Fulminant encephalomyocarditis Fulminant encephalomyocarditis

28. Diagnosis Age, Season, Location, Exposure Age, Season, Location, Exposure Clinical manifestation Clinical manifestation PCR PCR Culture from sterile sites biopsy Culture from sterile sites biopsy

29. Treatment: Supportive therapy Supportive therapy Pleconaril in immunocompetent Pleconaril in immunocompetent No Steroids No SteroidsPrevention: OPV/IPV OPV/IPV

30. Vaccination program Vaccination program At Birth: BCG’ OPV’ Hepatitis B* At Birth: BCG’ OPV’ Hepatitis B* 2 Month: DPT’ OPV’ Hepatitis B 2 Month: DPT’ OPV’ Hepatitis B 4 Month: DPT’ OPV 4 Month: DPT’ OPV 6 Month: DPT’ OPV’ Hepatitis B 6 Month: DPT’ OPV’ Hepatitis B 12 Month: MMR 12 Month: MMR 18 Month: DPT’ OPV 18 Month: DPT’ OPV 4-6 years old: DPT’ OPV’MMR 4-6 years old: DPT’ OPV’MMR 14-16 years old: Td 14-16 years old: Td