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Coxsackievirus vs. Kawasaki Disease

Coxsackievirus vs Kawasaki Disease Related Articles

What's the Difference Between Coxsackievirus and Kawasaki?

Coxsackieviruses are a common cause of infection. These viruses can cause diseases that range from very mild to life-threatening. Coxsackievirus infection is contagious and the virus can spread by coming into contact with respiratory secretions from infected patients.

Kawasaki disease is an acute condition that mainly affects previously healthy children between 6 months to 5 years of age. The diagnosis of Kawasaki disease is based on fever that lasts at least five days along with other signs and symptoms, which often appear in sequences rather than all at once. Kawasaki disease is currently the most common cause of acquired heart disease in children in the developed world.

  • Symptoms of coxsackievirus infections are usually mild. The coxsackievirus is one cause of the common cold or mild red rash. Symptoms of coxsackievirus may also include diarrhea, sore throat,
  • Less commonly, symptoms of severe coxsackievirus infection may include meningitis, encephalitis, chest pain, and inflammation of the heart.
  • Symptoms of Kawasaki disease include a fever of at least five days' and at least four of the following five criteria: red eyes without discharge, red and cracked lips or strawberry tongue, rash, swelling/redness/peeling of the hands or feet, large lymph nodes of the neck, or fewer of the above findings with evidence of coronary aneurysms or coronary enlargement seen on echocardiogram.
  • Kawasaki disease can be divided into 3 phases: The acute, early phase (fever and other major symptoms) lasting from five to 10 days and is followed by the subacute phase (development of coronary artery aneurysms) from 11-30 days. The convalescent phase (resolution of acute symptoms) lasts from four to six weeks.
  • There is no specific medicine or treatment that has been shown to kill the coxsackievirus but the body's immune system is usually able to destroy the virus on its own. Over-the-counter (OTC) pain relievers can be used to reduce pain and fever. OTC cold medicines (decongestants, cough syrup) may reduce symptoms in adults.
  • Treatment for Kawasaki disease includes admission to a hospital and administration of intravenous immunoglobulin and high-dose aspirin until the child's fever resolves, followed by low-dose aspirin for six to eight weeks until a normal echocardiogram has been obtained.
  • Most people who get coxsackievirus infections have no symptoms or are only mildly ill and soon recover. Severe coxsackievirus infections in newborns are fatal in approximately one-half of cases.
  • When Kawasaki disease is diagnosed and treated early, the incidence of coronary artery lesions decreases from 20% to 5%. It is very uncommon for patients who have no evidence of coronary abnormalities at two to three months after the acute illness to develop coronary abnormalities. Patients with larger coronary lesions have the greatest risk.

What Is Coxsackievirus?

Coxsackieviruses are a common cause of infection in adults and children. The spectrum of disease caused by these viruses ranges from very mild to life-threatening. No vaccine is available, and there is no drug that specifically kills the virus. Coxsackievirus infection is contagious from person to person. The key to prevention of coxsackievirus infection is good hand washing and covering the mouth when coughing or sneezing.

Being in settings where there is a high risk of exposure increases the risk of developing both viral and bacterial illnesses. Children attending day care, preschool, and grammar school may spread the infection among their peers. Newborn infants, as a consequence of their limited immune response, are extremely vulnerable to suffer substantial complications (including death) should they develop a coxsackievirus infection. Other older individuals with an underlying immune system weakness (for example, those receiving cancer chemotherapy) are also more likely to experience serious consequences should they develop a coxsackievirus infection.

The virus is present in the secretions and bodily fluids of infected people. The virus may be spread by coming into contact with respiratory secretions from infected patients. If infected people rub their runny noses and then touch a surface, that surface can harbor the virus and become a source of infection. The infection is spread when another person touches the contaminated surface and then touches his or her mouth or nose.

People who have infected eyes (conjunctivitis) can spread the virus by touching their eyes and touching other people or touching a surface. Conjunctivitis may spread rapidly and appear within one day of exposure to the virus. Coxsackieviruses are also shed in stool, which may be a source of transmission among young children. The virus can be spread if unwashed hands get contaminated with fecal matter and then touch the face. This is particularly important for spread within day-care centers or nurseries where diapers are handled. Diarrhea is the most common sign of coxsackievirus intestinal infection.

Like many contagious respiratory or intestinal illnesses, once the coxsackievirus enters the body, it takes an average of one to two days for symptoms to develop (incubation period). People are most contagious in the first week of illness, but the virus may still be present up to one week after symptoms resolve. The virus may be reside longer in children and those whose immune system is weak.

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What Is Kawasaki Disease?

Kawasaki disease is an acute illness associated with fevers that mainly affects previously healthy children between 6 months to 5 years of age. The diagnosis of Kawasaki disease is based on fever of at least five days' duration and a number of additional signs and symptoms, which often appear in sequences rather than all at once. Kawasaki disease is considered in any child with prolonged fever, regardless of other symptoms. Of note, Kawasaki disease is associated with a risk of developing critical widening of the arteries to the heart (coronary artery aneurysms) and subsequent heart attacks in untreated children. Kawasaki disease is currently the most common cause of acquired heart disease in children in the developed world.

The number of new cases per year (incidence) of Kawasaki disease remain highest in Japan, followed by Taiwan and then Korea, though the rates in Europe and North America are increasing. American children of Asian and Pacific Islander ethnic background have the highest rate of hospitalization.

Kawasaki disease was originally described in 1967 by a Japanese pediatrician, Dr. Tomisaku Kawasaki, and it was initially known as mucocutaneous lymph node syndrome (MCLNS).

What Are the Symptoms of Coxsackievirus vs. Kawasaki Disease?

Coxsackievirus

Most coxsackievirus infections are mild and may not even cause symptoms. The virus is one cause of the common cold or a generalized mildly erythematous (red) rash, especially seen in the summer months. It may also cause diarrhea or a sore throat that is similar to strep throat.

There are some more severe syndromes caused by the virus, but these are less common. They include meningitis (an infection of the linings of the spinal cord and brain), encephalitis (inflammation of the brain), pleurodynia (chest pain), and myopericarditis (inflammation of the heart). Infection of newborns may be particularly severe. These syndromes are described below.

Respiratory Illness

It is common for the coxsackievirus to cause a febrile upper respiratory tract infection with sore throat and/or a runny nose. Some patients have a cough resembling bronchitis. Less commonly, coxsackievirus may cause pneumonia.

Rash

Some people with coxsackievirus have a rash. In many, this is a nonspecific generalized red rash or clusters of fine red spots. The rash may not appear until the infection has started to get better. Although it may resemble a light sunburn, the rash does not peel. The rash itself is not contagious.

The virus may also cause small, tender blisters and red spots on the palms, soles of the feet, and inside the mouth. In the mouth, sores occur on the tongue, gums, and cheek. This condition is known as hand-foot-mouth disease (HFMD) and is caused by group A coxsackievirus. HFMD is most common in children under 10 years of age. HFMD usually causes a sore throat, fever, and the characteristic blister rash described above. It is mild and resolves on its own. While the blister fluid is a theoretical source of transmission of the virus, the large majority of those infected develop HFMD from contact with respiratory droplets or stool exposure.

Coxsackievirus also may cause a syndrome called herpangina in children. Herpangina presents with fever, sore throat, and small, tender blisters inside the mouth. It is more common in summer and is usually found among children 3-10 years of age. It may be confused with strep throat at first until test results for strep come back negative.

Eye Infection: Conjunctivitis

Acute hemorrhagic conjunctivitis (AHC) presents with swollen eyelids and red hemorrhages in the whites of the eye. Usually, the infection spreads to the other eye as well. Affected people may feel like there is something in their eye or complain of burning pain. AHC may be caused by coxsackievirus, although it is more commonly caused by a related virus. Symptoms usually resolve in about a week.
Meningiti


Coxsackieviruses, especially those from group B, may cause viral meningitis (inflammation of the linings of the spinal cord and brain). Viral meningitis is also known as "aseptic meningitis" because routine cultures of the spinal fluid show no bacterial growth. This is because routine culture methods test for bacteria and not for viruses. Patients with aseptic meningitis complain of a headache and fever with mild neck stiffness. A rash may be present. In children, symptoms may be less specific, including change in personality or becoming lethargic. Febrile seizures may occur in children. Seizures are less common in adults, although adults may complain of fatigue that lasts for weeks after the meningitis resolves.

Less commonly, coxsackievirus may cause inflammation of the brain tissue (meningoencephalitis), as well. People with meningoencephalitis usually have fever and are lethargic or confused. Meningoencephalitis is more common in small children.

Weakness and Paralysis

Another rare symptom is weakness in an arm or leg or even partial paralysis. The symptoms are similar to, but milder than, those caused by poliomyelitis. Paralysis or weakness may follow a bout of AHC or may occur on its own. Weakness and paralysis caused by coxsackievirus usually are not permanent.

Kawasaki Disease

Kawasaki disease is the result of an acute inflammatory process of medium-size blood vessels (vasculitis) that affects multiple organs in otherwise healthy children. The diagnosis of the disease is based upon criteria below.

The child must have a fever of at least five days' duration (with exclusion of other causes of fever) and at least four of the following five clinical features:

  1. Bilateral nonpurulent conjunctival injection (red eyes without discharge)
  2. Changes in the lips and oral cavity (red and cracked lips, strawberry tongue)
  3. Rash (nonpetechial, nonblistering)
  4. Changes in the extremities (swelling of the hands or feet, red hands or feet, peeling of the skin of the palms or soles)
  5. Cervical lymphadenopathy (large lymph nodes of the neck, often unilateral): Lymph node size is often >1.5 cm.
  6. Or fewer of the above findings with evidence of coronary aneurysms or coronary enlargement seen on echocardiogram

Typically, a child with Kawasaki disease will have a sudden onset of moderate fever (101 F-103-plus F) that has no apparent source. The fever lasts longer than five days, and the child is irritable and generally appears ill. In addition to the fever, the above symptoms may develop in any order and duration. The diagnosis is made when the above criteria are met and there is no other explanation for the symptoms, such as strep throat or an acute drug reaction. Other physical findings may be present and support the diagnosis:

  1. sore muscles and joints;
  2. abdominal pain without vomiting or diarrhea;
  3. liver or gall bladder abnormalities;
  4. abnormal lung function;
  5. meningitis;
  6. hearing loss;
  7. Bell's palsy; and
  8. testicular swelling and discomfort.

Kawasaki disease can be divided into phases. The acute, early phase (fever and other major symptoms) lasting from five to 10 days and is followed by the subacute phase (development of coronary artery aneurysms) from 11-30 days. The convalescent phase (resolution of acute symptoms) lasts from four to six weeks. For untreated patients, some develop coronary artery aneurysms that often will result in an acute heart attack (myocardial infarction) from months to years after the diagnosis.

The clinical features of Kawasaki disease can be mistaken for other illnesses such as streptococcal or staphylococcal infections (scarlet fever or toxic shock syndrome), parasite or viral infections (leptospirosis, measles, or adenovirus), and drug reactions (Stevens-Johnson syndrome). Acute mercury poisoning (acrodynia) has many signs and symptoms of Kawasaki disease.

In addition, some patients, especially toddlers or older patients, may develop incomplete Kawasaki disease or atypical Kawasaki disease in which the child may not have the four characteristic clinical features described above. Diagnosis in these situations is much more difficult. Patients with atypical Kawasaki disease are more likely to develop coronary artery disease.

What Causes Coxsackievirus vs. Kawasaki Disease?

Coxsackievirus

Coxsackieviruses are part of a viral genus called Enterovirus. They are divided into two groups: group A coxsackievirus and group B coxsackievirus. Each group is further divided into several serotypes. The virus is not destroyed by the acid in the stomach, and it can live on surfaces for several hours.

Kawasaki Disease

The cause of Kawasaki disease is not completely known. There are a number of theories regarding the cause, but so far, none have been proven. Some believe that the disease is caused by an infection since outbreaks are commonly clustered and appear similar to other infectious diseases (abrupt onset, fever, rapid resolution of symptoms within one to three weeks). It is thought that a bacterial toxin, acting as a disease trigger, initiates the disease. This toxin may come from common bacterial infections in children, such as Staphylococcus or Streptococcus.

What Is the Treatment for Coxsackievirus vs. Kawasaki Disease?

Coxsackievirus

There is no specific medicine that has been shown to kill the coxsackievirus. Fortunately, the body's immune system is usually able to destroy the virus. In cases of severe disease, physicians have sometimes turned to therapies that seem promising but which have not been thoroughly tested to see if they really work. For example, some reports suggest there might be a benefit to intravenous immune globulin (IVIG), which is made from human serums, which contains antibodies.

Treatment for myopericarditis is supportive. This includes using medicines to support the blood pressure if the heart is pumping too poorly to do so by itself. In extreme cases, heart transplantation may be needed.

Acetaminophen, ibuprofen, and similar agents can be used to reduce pain and fever. Avoid the use of aspirin in children and teenagers, because of the risk of a serious liver disorder (Reye's syndrome).

Over-the-counter cold preparations (decongestants, cough syrup) may reduce symptoms in adults, although they will not speed recovery and may cause side effects including drowsiness and dry mouth. The efficacy of these products has recently been challenged by the U.S. Food and Drug Administration (FDA), which recommends against their use in children under 6 years of age. There are no studies showing that over-the-counter medicines work in older children.

Kawasaki Disease

There are no unique or specific tests seen in Kawasaki disease. There are, however, a number of blood, urine, and spinal fluid studies that support the clinical diagnosis. These might include throat cultures, urine cultures, and blood counts. All children with possible Kawasaki disease should have an electrocardiogram (ECG) and echocardiogram (ECHO) to evaluate the child's coronary arteries.

Once Kawasaki disease is diagnosed, it is imperative to initiate treatment within 10 days of the onset of the child's fever. This is due to the fact that the damage to the coronary arteries usually occurs after the 10th day of illness during the subacute phase of the disease. The current recommended therapy includes admission to a hospital and administration of intravenous immunoglobulin (IVIG or gammaglobulin) and high-dose aspirin until the child's fever resolves, followed by low-dose aspirin for six to eight weeks until a normal echocardiogram has been obtained. If a child has any evidence of coronary artery abnormality, a pediatric cardiologist can continue to follow monitor the patient.

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What Is the Prognosis for Coxsackievirus vs. Kawasaki Disease?

Coxsackievirus

Most people who get coxsackievirus infections have no symptoms or are only mildly ill and soon recover. People who have fever or feel ill should stay home, because the infection is contagious.

Most patients with myopericarditis recover completely, but up to one-third will continue to have some degree of heart failure. Children with myopericarditis usually fare better than adults. Severe coxsackievirus infections in newborns are fatal in approximately one-half of cases.

Kawasaki Disease

Kawasaki disease is the most common cause of acquired heart disease in children in the developed world. When diagnosed and treated early, the incidence of coronary artery lesions decreases from 20% to 5%. It is very uncommon for patients who have no evidence of coronary abnormalities at two to three months after the acute illness to develop coronary abnormalities. Patients with larger coronary lesions have the greatest risk, and it has been shown that patients with giant aneurysms (>8mm) have a highest risk of developing future heart attacks (myocardial infarctions). The long-term risk of patients with small aneurysms is currently unknown.

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References
"Coxsackievirus A6 and Hand, Foot, and Mouth Disease, Finland." United States Centers for Disease Control and Prevention. Dec. 7, 2010. <http://wwwnc.cdc.gov/eid/article/15/9/09-0438_article>.

American Heart Association. <http://www.americanheart.org>.

Burns, Jane C., et al. "Kawasaki Disease: A Brief History." Pediatrics 106.2 (2000): e27.

Gerding, R. "Kawasaki Disease: A Review." Journal of Pediatric Health Care 25.6 Nov.-Dec. 2011: 379-387.

Harnden, A., M. Takahashi, and D. Burgner. "Kawasaki Disease." BMJ 338 (2009): 1133-1138.

Kawasaki Disease Foundation. <http://www.kdfoundation.org>.

Sun, Mary Beth, and Jane Newberger. "Kawasaki Disease." Pediatrics in Review 34.4 April 2013: 151-160.
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