Systemic infections caused by enteroviruses

Introduction to various systemic infections caused by enterovirus Enteroviruses include poliovirus, cox-sackievirus, enterocytopathic human- phanvirus (ECHOvirus), and new enterovirus type 68-71 newly discovered in recent years. The relationship between Coxsackie virus and Echovirus and new enterovirus and human diseases. These viruses cause widespread or epidemic morbidity around the world, affecting various systems of the whole body, and are increasingly valued by people, especially in childhood. . The clinical manifestations are complex and diverse, although most of them are mild, but they can also be life-threatening. Can cause aseptic meningitis, polio, myocarditis, epidemic chest pain, rash disease, herp angina, respiratory tract infection, infant diarrhea and epidemic acute conjunctivitis. basic knowledge The proportion of illness: 0.005% Susceptible people: good in childhood Mode of infection: non-infectious Complications: herpetic angina inflammatory disease meningitis

Etiology of various systemic infections caused by enterovirus

The most characteristic of Coxsackie virus is that it can cause disease in mice. According to the different pathogenic diseases of the suckling mice, it can be divided into two groups: A and B. A group of viruses has been found to have 23 types (A1~24 type, among which Type 23 has been classified as Eke 9). This group of viruses can cause extensive skeletal muscle myositis and necrosis in suckling mice, causing flaccid paralysis, but most of them are difficult to separate in tissue culture. Group B virus has been found to type 6 ( Types 1 to 6 can cause focal myositis and brown fat necrosis, myocarditis, hepatitis, encephalitis, pancreatitis, etc., causing limb tremors and tonic paralysis. Group B viruses can be isolated in tissue culture.

Echovirus has found 31 types (types 1 to 34, of which types 10, 28, and 34 have been classified as other viruses), which are only infectious to humans, but not to suckling mice, monkey kidney or human kidney cells. Echovirus is very sensitive and is commonly used to isolate viruses. Since 1986, a new enterovirus type 68-71 has been discovered that is immunospecifically different from known coxsackieviruses and echoviruses. There is generally no cross-immunization, and only a few types have antigenic crossovers.

The virus invades from the pharynx or intestine, propagates in the local mucosa or lymphoid tissue, and is locally excreted. At this time, local symptoms may occur, and then the virus invades the local lymph nodes, thereby entering the blood circulation and causing viremia (first time) Viremia), the virus can be carried along the bloodstream to various organs of the body such as the central nervous system, skin and mucous membranes, heart, respiratory organs, liver, pancreas, muscles, etc., where further propagation causes lesions and re-enters the blood circulation, causing Viremia (second viremia).

Different virus strains have different tissue tropism and different target organs, which cause different systemic diseases. The pathological changes are different depending on the organs and extents. The central nervous system lesions are similar to polio, but generally lighter, with meningeal inflammation. More common, encephalitis patients with focal mononuclear cell infiltration and degeneration, Coxsackie B virus infection often causes extensive lesions in the newborn, involving the brain, liver, heart, focal necrosis, with lymph Cell and neutrophil infiltration, patients with myocarditis often have interstitial blood stasis and inflammatory cell accumulation, myocardial fibrotic necrosis, nuclear pyknosis, rupture, pericardial inflammatory infiltration, etc., muscle can be seen in severe cell infiltration or muscle fiber necrosis.

Prevention of various systemic infections caused by enterovirus

Paying attention to environmental hygiene and personal hygiene, and strengthening physical exercise will help prevent the epidemic. For infants and young children who are exposed to the patient, they can inject 3 to 6 ml of gamma globulin or 6 to 9 ml of placental globulin to prevent infection. A live attenuated polio vaccine that produces intestinal disturbances and controls the prevalence of aseptic meningitis caused by other enteroviruses. This is a non-specific preventive measure that deserves further study due to the Coxsackie virus. There are many types of Echovirus and other enteroviruses. Therefore, preparation-specific vaccines have certain difficulties, and they are not universally applicable. In recent years, many people have advocated some types related to pandemic, such as frequent sterility. Coxsackie A7 and Ecotype 9 viruses, which are prevalent in meningitis, and Coxsackie B group 2, 3, 4, and 5 viruses, which often cause severe myocarditis, should actively prepare live attenuated vaccines.

Complications of various systemic infections caused by enterovirus Complications herpes angina meningitis

The disease may have complications of various systems, such as epidemic myalgia, herpetic angina, infant acute myocarditis, aseptic meningitis, acute epidemic conjunctivitis, and other complications.

Symptoms of various systemic infections caused by enteroviruses Common symptoms, rash, sputum, maculopapular congestion, convulsions, purpura, gait instability

Systemic diseases

(a) the brain

1. Spastic diseases: Since the widespread use of polio vaccine, it has been found that paralysis caused by enterovirus is not uncommon. Coxsack A7,9,10,B1~5, Echo 4,6,9,11, 14,30 can be caused, but enterovirus 71 is a non-poliovirus that can cause epidemic sputum. This virus can cause myositis in mice and sputum in monkeys. Shanghai has also seen Coxsackie virus B1. Cases of sputum caused by type B5 and Echovirus type 9 are generally mild in symptoms and quickly recover, leaving little sequelae, but severe cases can also cause medullary paralysis in a pandemic. Reported Coxsack A2,5 6,6 and erco 6,22 cause multiple radiculitis.

2, encephalitis: Coxsackie virus has also been isolated from cases of summer encephalitis, and some even think that 15% of summer encephalitis is caused by Coxsackie virus, Coxsack A2, 5, 7, 9 and B2, 3,4 can cause encephalitis, Ecco 4,6,9,11,30 can also be caused, especially Eke 9 is more common, Shanghai from the case of summer encephalitis, has been isolated Coxsackie virus A9, and B3, as well as Echovirus types 3 and 9, were confirmed to be pathogens.

The clinical manifestations of encephalitis caused by enterovirus are similar to those of JE. There may be fever, confusion, convulsions, coma, balance disorders, etc., which may be associated with abnormal EEG. The number of cells in cerebrospinal fluid examination is more than <100/mm3, to monocytes. Mainly, it can always be normal, the protein is slightly increased, the sugar is normal, and Coxsackie B3,6, Echo 2,9,17,25 and enterovirus 71 have been isolated from brain tissue and cerebrospinal fluid.

Coxsackie B virus can cause extensive encephalitis in newborns and infants, often accompanied by myocarditis and hepatitis. The disease is multiple-risk, acute onset, frequent convulsions, prone to respiratory failure, severe cases can be fatal, 1973-1974 In Hubei, a case of brain-myocarditis caused by Coxsackie virus was reported. The incidence of symptoms was less than 1 year old. In full-term neonates, mild viral encephalitis was common. Only fever, appetite, vomiting and diarrhea were 1-2 times. Cerebrospinal fluid can have a positive finding, and the course of disease is usually 3 to 4 days.

(B) heart disease (acute myocarditis and pericarditis, etc.)

Mainly caused by Coxsackie B2,3,4 virus, about 1/3 to 1/2 of the heart disease caused by it, A4,16 and Echo 6,8,9,22,30 virus can also be triggered, Some people think that when Coxsackie B virus infection is prevalent, 33% of patients have heart disease, mostly in newborns and infants, and occasionally in older children. In recent years, there have been many adult diseases, mostly in adolescence and younger people. Most of them are sporadic, more men than women. In the 1980s, Chinese scholars isolated Coxsackie B virus from cases of Keshan disease. The serology confirmed mainly B3, B5. Animal experiments found that the virus directly invaded muscle fibers, and necrosis and inflammation occurred. The clinical symptoms of heart disease can be light and heavy, and the light has no symptoms. In severe cases, heart failure can occur suddenly. Generally, there is a short-term fever and cold symptoms. It takes about 7 to 10 days, followed by cardiac manifestation and fatigue. , chest pain, pulse rate, shortness of breath, etc., the clinical manifestations of the heart can be summarized into the following types.

1, acute heart failure: more common in newborns, adults can also occur, sudden onset, cough, pale, cyanosis and difficulty breathing, but also rapid heart failure, heart sounds low blunt, heart rate increased, liver sharply increased Large, with pulmonary edema, ECG showed low voltage, tachycardia, T wave inversion and ST segment low equality, acute pericarditis may occur with or with myocarditis, serum myocardial enzymes often increase in acute myocarditis.

2, arrhythmia: clinical manifestations of premature beats, tachycardia or various types of conduction block, ECG examination can help diagnose, light recovery, but also can not recover for several months, or even repeated attacks for several years For a long time, this type is the most common.

3, sudden death: often occurs at night, autopsy confirmed myocardial ischemia infarction or extensive myocardial necrosis, can find intestinal virus antigen in cardiomyocytes.

4, chronic cardiomyopathy: In recent years, countries have reported a number of subacute or chronic heart disease caused by Coxsackie B virus, involving the heart conduction system, endocardium, heart valve or pericardium, causing fibroelastosis, Chronic cardiomyopathy, stenotic pericarditis, etc., fetal infection can lead to congenital heart disease, such as congenital calcified whole heart disease.

About one-third of patients, especially newborns and infants, may be associated with neurological symptoms such as vomiting, convulsions, and unresponsiveness. The cerebrospinal fluid may have mononuclear cells or complete normality, which may be called brain-myocarditis.

(three) epidemic myalgia

Or epidemic chest pain, (epidemicpleurodynia, Bornholm disease), mostly caused by coxsackievirus group B type 1 to 6, but group A 1,4,6,9,10 and echovirus 1,2,6 Type 9 can also cause, and it often occurs in local areas. It is more common in older children and young adults. Family members can develop disease at the same time or at the same time. The incubation period is 2 to 5 days, which can be extended to 2 weeks, mainly due to fever. Up to 39 ° ~ 40 ° C) and paroxysmal myalgia, can affect the muscles of the body, and the most common in the abdomen, especially the diaphragm is most susceptible, muscle pain is different, and even severe can cause shock, children are lighter, Muscle activity increased muscle pain, no abnormal findings on chest X-ray examination, muscle pain more than 4 to 6 days (12 hours to 3 weeks) after the disappearance of the disease, the disease can be intermittent recurrent, but more self-healing.

(four) herpes angina (herpangina)

It is mainly caused by Coxsackie group A virus, among which A2,4,6,9 (1~10), 16,22 type are more common, group B type 1~5 virus can also cause disease, and Echo virus causes There are fewer people, the disease spreads all over the world, is sporadic or popular, and is highly contagious. The incubation period is about 4 days on average. It is characterized by fever, sore throat (painful pain when swallowing), pharyngeal congestion, and scattered grayish white herpes in the pharynx. Diameter 1 ~ 2mm, surrounded by blush, herpes collapsed to form a yellow ulcer, ranging from 1 to 2, up to more than 10, generally 4 to 5, such mucosal rash is more common in tonsils, soft palate and uvula , usually self-healing after 4 to 6 days, the surrounding white blood cells and classification are normal.

(5) rash disease

There is often a rash in the process of enterovirus infection. The 2, 4, 9 and 16 types of coxsackievirus group A and the type 3, 5 and 5 of group B are closely related to the rash. Echovirus 4, 9, 16 There are many rashes in the infection, infants and children often accompanied by rash, adults are less common, most of the incubation period is 3 to 6 days, often with fever and upper respiratory symptoms such as mild cough, sore throat, etc., and then rash, rash It is pleomorphic, with rash, maculopapular rash, rubella-like rash, herpes or measles-like rash, etc. It also has rash when it is hot, most of which is caused by Echovirus type 16, which is easy to be mistaken for children with acute rash, Coxsack A9 Frequently caused by ecchymosis, in addition to rash, sometimes accompanied by swelling of the whole body or neck and post-occipital lymph nodes.

(6) Respiratory infections

Enteroviruses often cause upper respiratory tract infections. For example, coxsackieviruses A21, 24 and B2-5 have caused the prevalence of light respiratory infections. A21 is mostly prevalent in military camps, and the positive rate of throat swabs is high. Echovirus 4,7, 11,20,25,30 and other types can cause certain flu-like diseases or pharyngitis. Coxsack B1,4 can cause bronchitis, Coxsackie A9,16 and B4,5, and EK9,19 virus It can cause lower respiratory tract infections such as pneumonia and bronchiolitis in infants. It can cause persistent dyspnea, purpura, hypoxia, etc., and even death due to asphyxia. Enterovirus type 68 has been proven to be the cause of pneumonia and bronchiolitis.

(7) hand, foot and mouth disease (hand, food and mouth disease )

Since the discovery of the disease in 1960, it has been reported in Europe and the United States, mainly caused by Coxsackie virus A5, 9, 10, 16 and B2,5, especially A16 is more common, enterovirus 71 can also be caused, there are The report separates the pathogenic virus from the rash. The disease is highly contagious. It is common in the whole family and can cause local outbreaks. After 1983, Beijing, Shanghai, and Northeast China have reported many times. The patients were 4 to 5 years old. More, about 80% or more, adults can also be sick, mostly mild, all seasons can be onset, more than 5,6 months, incubation period of 2 to 5 days, initial symptoms of low fever, runny nose, anorexia, mouth Pain, vomiting, diarrhea, etc., small herpes on the oral mucosa, often distributed in the tongue, buccal mucosa, hard palate, can also be seen in the gums, tonsils and pharynx, and soon the herpes collapses into ulcers, at the same time can appear in stomatitis The maculopapular rash, which is mostly in the hands and feet, is located in the back of the hand, between the fingers, occasionally in the trunk, thighs, buttocks, upper arms, etc., the maculopapular rash is quickly turned into a small herpes, which is smaller than the chickenpox rash, and the texture is slightly hard, from several to Dozens, self-absorption within 2 to 3 days, no sputum, prognosis Good, more self-healing, but can relapse, sometimes accompanied by aseptic meningitis, myocarditis and so on.

(eight) infant diarrhea

Echovirus is closely related to infantile diarrhea. The 6,7,11,14,18 virus is often isolated from the feces of the child. The type 18 virus has caused the epidemic of diarrhea in the baby. The foreign report has caused diarrhea in children. Viruses 9,10,12,13,14,22,23,24, Coxsackie virus group A, 9,17,18,20-24, and group B, 2,3, domestic since 1963 In the Fuzhou, Shanghai, Guangxi and other places, the Echovirus was isolated from the faeces of diarrhea patients; the genus 7 and 18 were isolated in Shanghai. In 1973, the Baise baby diarrhea in Guangxi was separated from Ekor 1,2,3,7,24. Type and Coxsackie B5 virus, the clinical symptoms are similar to those of normal infants with diarrhea, mostly mild. It has been reported that Echo 11 virus can cause fat sputum. Because of the high positive rate of intestinal virus culture in healthy children, It is necessary to have other epidemiological and serological evidence for the diagnosis of diarrhea.

(9) Acute epidemic hemorrhagic conjunctivitis (acute epidemichemorrhagic conjunctivitis)

After the disease was first discovered in 1986, it was reported in West Africa, North Africa, Singapore, Japan, Indonesia, South Asia, and Europe. It was also popular in East China and Hong Kong in 1971. The characteristics of the isolated strains were slightly different. Enterovirus, because it is different from the known Coxsackie and Echovirus in immunology, it is called the new enterovirus type 70. Coxsackie A24 can also cause this disease. In 1986, India had a big problem. Popular, the disease is very contagious, often outbreaks, the number of patients can reach tens of thousands to millions, children can get sick in adults, the family is highly disseminated, more than 70% of the victims, hand-to-eye infection There are very few viruses isolated from feces and throat swabs. The incubation period is about 1 day. The main clinical manifestations are acute conjunctivitis, redness and swelling of the eyelids, conjunctival congestion, tearing, thick secretions and subconjunctival hemorrhage, but rarely involving the sclera. And the iris, the parotid gland can be swollen, the systemic symptoms are very rare, most of them self-healing within 1 to 2 weeks. In India, it was reported that asymmetrical limb paralysis occurred 2 to 5 weeks after the recovery of eye diseases, resembling polio, but the cerebrospinal fluid has Correct High level specific antibody to enterovirus type 70.

(10) Neonatal coxsackie virus and echovirus infection

In addition to similar clinical manifestations of neonatal infantile enteritis, there are also many serious systemic infections, most commonly caused by Coxsackie B2-5 and Ecker 11, a few by Coxsackie. A3, 9 and 16, mostly from the mother to these viruses, but can also be obtained from the hospital staff, the intra-fetal infection is early, and most of the infection is caused by the birth, the incidence is a little late, the neonatal room outbreak is Many reports, both at home and abroad, generally start from 3 to 7 days after birth. Early general symptoms are mild, no specialities, such as restlessness, reduction, temporary dyspnea, fever may be optional, sometimes in There may be 1 to 7 days of symptoms between the prodromal symptoms and severe symptoms. The systemic severe symptoms are mainly acute myocarditis or extensive hepatitis, myocarditis, often caused by group B coxsackie virus, often accompanied by encephalitis, newborn Sudden dyspnea, heart rate often exceeds 200 beats per minute, heart enlarges, systolic murmurs and ECG changes, and finally death from heart failure and shock, often accompanied by multiple organ damage such as the brain Liver, pancreas, adrenal gland disease have mortality is generally 50% or less, survivors of myocardial function can be restored in the short term, a few weeks delay.

Most of the severe hepatitis in newborns is caused by the Ecco 11 virus. It is also reported to be caused by Echoviruses 4,6,7,9,12,14,19,21 and 31. The initial symptoms include antifeeding and lethargy, and jaundice is deepened. Within 2 days, the disease progresses and there is bleeding tendency, skin ecchymosis, acidosis, hemorrhagic symptoms, liver failure, renal failure, convulsions, abnormal liver function, elevated transaminase, decreased platelets, prolonged prothrombin time, white blood cell count And the classification is normal, more than 80% of the babies die within 2 to 6 days. The autopsy often finds large necrosis and diffuse hemorrhage of the liver. It is also reported that Coxsack 3, Echo 6,9,11 virus causes neonatal pneumonia, and the prognosis is also Poor, in the neonatal infected person nasopharyngeal secretions, feces, urine, cerebrospinal fluid isolated virus, serum antibodies can also rise.

(11) Chronic meningoencephalitis in patients with low immunity

In patients with congenital or secondary B lymphocyte defects, most patients with X-linked gamma globulin deficiency can develop chronic, persistent central nervous system lesions, mostly caused by Echovirus, and some individuals The report is caused by Coxsackie A4, 11, 15 or B group 2, 3, starting with no neurological symptoms or only headache, light neck stiffness, lethargy, lack of exercise, post limb tremor, fundus edema, shock Unstable gait, ataxia, these symptoms, signs can be light and heavy, fluctuations in the course of the disease, increased cerebrospinal fluid lymphocytes, protein is higher than general aseptic meningitis, can be repeatedly detected from the cerebrospinal fluid for several months It will be several years, but the positive rate in feces is low. The brain, lung, liver, spleen, kidney, heart muscle, skeletal muscle and bone marrow can sometimes detect the virus. Therefore, it is believed that this disease is caused by the virus directly invading the organs. There is a decrease in T lymphocyte transformation during the course of the disease. The central nervous system has chronic meninges and brain tissue inflammation, nerve cells are missing, and glial cells are proliferated, but the lesions are not as extensive and severe as polio, and most patients are dying. Die.

(12) Others

Enterovirus can still invade the parotid gland, liver, pancreas, testis and other organs, causing corresponding clinical manifestations. In recent years, it has been considered that enterovirus infection has a certain relationship with rheumatism, nephritis, hemolytic uremic syndrome, diabetes and so on.

Examination of various systemic infections caused by enterovirus

(a) surrounding blood

The white blood cell count is mostly normal, and it can be increased in some enterovirus infections, and neutrophils can also be increased.

(two) virus isolation

Throat swabs and feces are generally used for virus isolation and verification. Viruses can be isolated from the tissues obtained from the patient's cerebrospinal fluid, pleural effusion, pericardial effusion, blood, blister, biopsy or autopsy. After the specimen is obtained, it should be sent immediately. Can be inoculated in monkey kidney, human embryonic kidney, human amniotic membrane, human diploid or Hela cells, tissue culture in KB passage cells, observe cytopathic, and use a variety of tissue culture cells for separation can increase the positive rate, positive specimens The specific type of immune serum is used for neutralization test for type identification. If the Coxsackie group A virus is suspected, the specimen should be inoculated subcutaneously, intraperitoneally or intracerebrally to inoculate the mouse for virus isolation. The positive rate is not high, and Coxsackie B virus can also cause disease in suckling mice.

(three) serum immunology test

Take double serum, determine the level of specific antibody, generally can be determined by neutralization test, complement binding test, enzyme-linked immunosorbent assay (ELISA, enzyme labeling), radioimmunoassay, etc., the neutralization test is the most reliable, medium And the antibody disappears the slowest, and the type specificity is also strong. If the antibody level in the recovery period is 4 times higher than the early stage, it has great diagnostic significance, but due to the large number of enterovirus types, the serological neutralization test workload Large, only when a known type of enterovirus is prevalent in some places, it is ideal to diagnose this method.

(4) Immunofluorescence rapid diagnosis method

The use of fluorescently-stained immunological antibodies to identify antigens can achieve rapid diagnosis. However, in addition to the application of poliovirus infection, it is not used much in the case of enterovirus infection, because various types of specific immune serum are required. There are many procedures, and recently, the VP3-ZC antigen shared by many serotypes and a monoclonal antibody that cross-reacts with the VP1 capsid protein of multiple serotypes have improved the immunodiagnostic method, but it is still in the research stage.

(5) Nucleic acid hybridization

Due to the homology between different serotypes of enterovirus genomes, especially the 5' non-coding region is highly conserved, it can be used for nucleic acid hybridization, which has made a new leap in the identification of enterovirus in recent years. There are three types of needles:

1 cDNA probe, using a fragment of viral RNA as a template, catalyzed by reverse transcriptase, large polyclonal in plasmid vector, and then incorporated with a chromogenic gene (biotin or digoxin) or isotope Go to the newly synthesized cDNA strand and mark it. If the specimen is cultured for 12 to 24 hours, the positive rate can be increased.

2RNA probe - Since RNA is a single-stranded molecule, its hybridization reaction with target sequences is extremely efficient. Generally, a specific transcription vector is used to clone enterovirus RNA probes. Mixing several RNA probes can make the detection of virus types wider. RNA probes are superior to cDNA probes in terms of specificity and sensitivity.

The oligodeoxynucleotide probe has the following advantages over the above two probes, because the chain is short, the time of complete hybridization with the same target site is short, and the change of one base in the target sequence can be recognized, and the point mutation can be detected. It can be synthesized in large quantities at a low price. Because of the selection of the 5' non-coding region common sequence, this probe can be firmly and specifically combined with most clinical common enteroviruses, in order to overcome the low intestinal virus titer in the specimen. In recent years, PCR has been used to amplify a single gene or a short DNA sequence and then hybridize with a probe. This method has been applied to the clinic. When the enterovirus central nervous system infection is prevalent, the enterovirus RNA is detected from the cerebrospinal fluid. The rate is high, and the result can be obtained within 24 hours. It takes much faster than the virus culture to take 6-8 days. The clinical specimens are amplified by PCR and then hybridized with non-isotopically labeled enterovirus probes, and the results are obtained in a few hours. Greatly helpful for clinical diagnosis.

Diagnosis and identification of various systemic infections caused by enterovirus

diagnosis

Diagnosis can be performed based on clinical manifestations and examinations.

Differential diagnosis

(1) Aseptic meningitis: It should be distinguished from meningoencephalitis caused by other viruses:

1, epidemic mumps: with meningoencephalitis, more prevalent in winter and spring, often accompanied by parotid swelling, serum amylase can be increased, but Coxsackie virus B3, Echovirus 9,16 can also cause parotid swelling , it is not easy to identify.

2, ridge, polio: viral meningitis caused by the virus, such as accompanied by sputum is easier to diagnose, because Coxsackie virus and Echo virus infection rarely occur sputum, and mostly mild, most do not leave sequelae.

3, Japanese encephalitis: more concentrated in the summer and autumn, the onset of acute, more with the change of mind, the peripheral blood and cerebrospinal fluid increased leukocytosis, the high percentage of neutrophils is its characteristics.

4, epidemic cerebrospinal meningitis and other purulent meningitis: mild or not completely treated, especially need to be identified, acute onset, meningeal irritation is obvious, cerebrospinal fluid examination is generally more neutrophils, sugar and Chloride reduction, if the pathogenic bacteria can be found in the cerebrospinal fluid can be diagnosed, the total number of white blood cells and neutrophils increased.

5, tuberculous meningitis: slow onset, there are other tuberculosis and tuberculosis contact history, cerebrospinal fluid sugar and chloride decreased, there is a film formation, can be found tuberculosis, tuberculin skin test positive.

6, cryptococcal meningitis: multiple onset is slow, the course of disease is repeated, easy to have sequelae.

7, infantile beriberi (vitamin B1 deficiency) and other causes of encephalopathy (such as toxic encephalitis): should be careful not to be confused with enteroviral encephalitis, detailed medical history and careful physical examination is important .

Aseptic meningitis caused by enterovirus is not easy to be differentiated from other viruses, but it occurs in summer and autumn, and there is a trend of rash, myalgia, mouth, pharyngeal herpes, myocarditis and other intestines. When the virus is common, it is quite helpful for diagnosis.

(B) epidemic myalgia: chest pain should be differentiated from pleurisy, angina pectoris, myocardial infarction, chest X-ray and electrocardiogram to help diagnose, abdominal pain is similar to appendicitis, in addition to adult cholecystitis, cholelithiasis, Gastric ulcer perforation, acute pancreatitis, etc., myalgia is generally limited to superficial parts, no deep tenderness or rebound tenderness. In addition, abdominal inflammation is often accompanied by peripheral white blood cell count and neutrophil increase, and this disease is normal, acute pancreas In the case of inflammation, serum amylase can be increased.

(C) acute myocarditis, pericarditis: neonatal myocarditis often associated with other acute infections, sepsis, pneumonia, etc., such as rapid symptoms of heart failure or arrhythmia, suspected and enterovirus infection, accompanied by rash, serum aminotransferase Elevation and changes in cerebrospinal fluid are more helpful in diagnosis. Myocarditis occurs in older children and adolescents. Patients with pericarditis should first exclude rheumatism. The latter often have arthritis symptoms and anti-streptolysin "O" test. Mucin and C-reactive protein increase help to identify, myocarditis in middle-aged and above needs to be differentiated from coronary heart disease.

(4) herpes angina, hand, foot, mouth disease: need to distinguish from stomatitis caused by herpes simplex, herpes angina often occurs, its oral herpes is often limited to the back of the mouth, hands, feet, mouth disease It is often spread in a small range to form a local epidemic. The herpes of the front of the mouth is prone to ulceration, accompanied by a small, hard rash. The herpes simplex is often a sporadic case, and the lesion can occur in any part of the mouth, but It is more common to have skin and mucous membrane junctions.

(5) rash disease: plaque in pleomorphic rash needs to be differentiated from measles and rubella, usually with little ear, post-occipital lymphadenopathy, no post-pigmentation or desquamation, Ek 16 Infected rash appears after heat retreat and should be differentiated from infantile rash. Scarlet fever-like rash needs to be distinguished from scarlet fever. General symptoms and pharyngeal inflammation are milder than scarlet fever. Patients with herpes should be identified with chickenpox, such as hands, feet, and mouth. The shape of the diseased rash is smaller than that of chickenpox. The skin is thick and hard, and it is mostly distributed in the hands and feet. It is rare in the trunk.

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