Coxsackieviruses Workup

Updated: Feb 02, 2022
  • Author: Martha L Muller, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Approach Considerations

Enteroviruses may be excreted in human feces for up to 3 months after infection. However, an apparent clinical course correlates with the acute phase of infection, during which time virus can be found in the throat, blood, and various organs.

When considering HFMD, establishing a clinical diagnosis is the mainstay.


Laboratory Studies

Definitive diagnosis can be made based on isolation of the virus in cell culture. Cytopathic effect can usually be seen within 2 to 6 days. Samples are normally taken from the stool or rectal swabs, but may be isolated from the oropharynx early in the disease course. However, given improved sensitivity and faster turn-around time, polymerase chain reaction (PCR) has emerged as the most prominent diagnostic tool used for enteroviral detection. Serology is also available as a diagnostic modality but can be difficult to interpret. Traditionally, enteroviral infections have been noted after a rise in neutralizing antibodies titer (at least a 4-fold rise in titer between acute and convalescent phase).

Aseptic meningitis

The workup needs to rule out bacterial meningitis, and appropriate antibiotics should be administered until the workup is complete. Diagnosis requires cerebrospinal fluid (CSF) evaluation, which tends to show a lymphocytic predominance, normal-to-decreased glucose levels, and normal-to-slightly elevated protein levels. The virus can be isolated via PCR (sensitivity, 66%-90%) and, less commonly, cell culture (sensitivity, 30%-35%). A recent study in infants reported that routine CSF PCR for enteroviruses resulted in shorter hospital stays (by 1.54 days) and a decreased duration of antibiotic use (by 33%).


Diagnostic workup requires CSF evaluation, which yields findings similar to those of aseptic meningitis.


Diagnosis is generally circumstantial, with evidence of infection from the oropharynx, feces, or on serology.

Acute hemorrhagic conjunctivitis (AHC)

Diagnosis requires conjunctival swabs or scrapings, which are 90% successful. A rising antibody titer can be demonstrated.


Imaging Studies

Head CT scanning without contrast may be obtained upon initial presentation of meningitis and/or encephalitis to rule out hemorrhage, increased intracranial pressure, or mass lesions.

Echocardiography can be used to evaluate overall cardiac function and valvular disease in patients with myopericarditis and heart failure.


Other Tests

Obtain a throat culture to rule out streptococcal pharyngitis and/or tonsillitis.

HIV testing is always appropriate in patients who present with nonspecific febrile illness or rashes.

An EEG can be used to detect the presence of and localize seizure activity.

ECG changes in myopericarditis include ST-segment elevations or nonspecific ST segment, T-wave abnormalities, arrhythmia, and heart block.



Lumbar puncture is crucial in the evaluation of meningitis and/or encephalitis.

Skin biopsy may be helpful in the evaluation of nonspecific exanthems.

Obtain a Tzank smear to rule out herpes virus infection.


Histologic Findings

Intracytoplasmic viral particles may be observed, especially with skin lesions and/or rashes of HFM.