Management of Coxsackievirus (Enterovirus) Infection in the Emergency Department
I believe you are asking about coxsackievirus (an enterovirus), not "coexivirus" - the provided evidence focuses on COVID-19, which is not relevant to coxsackievirus management.
Clinical Presentation
Coxsackievirus patients typically present with fever, and clinical manifestations vary by viral subtype:
- Coxsackie A virus: Hand-foot-mouth disease (vesicular lesions on palms, soles, oral mucosa), herpangina (painful oral vesicles/ulcers on posterior pharynx), acute hemorrhagic conjunctivitis
- Coxsackie B virus: Myocarditis, pericarditis, pleurodynia (Bornholm disease with severe chest/abdominal wall pain), aseptic meningitis, neonatal sepsis-like illness
Emergency Department Evaluation
Obtain targeted history focusing on:
- Fever pattern and duration
- Characteristic rash or oral lesions
- Chest pain, dyspnea, or palpitations (cardiac involvement)
- Severe headache, neck stiffness, photophobia (meningitis)
- Age and immune status (neonates and immunocompromised at higher risk)
Physical examination priorities:
- Vital signs with careful attention to hemodynamic stability and respiratory status
- Skin examination for vesicular rash on hands, feet, buttocks
- Oral cavity for vesicles/ulcers
- Cardiac auscultation for murmurs, rubs, or gallops
- Neurological examination including meningeal signs
Diagnostic workup based on presentation:
- Suspected myocarditis/pericarditis: ECG, cardiac troponin, echocardiography, chest X-ray
- Suspected meningitis: Lumbar puncture with CSF analysis (lymphocytic pleocytosis typical), CSF enterovirus PCR
- Hand-foot-mouth disease: Clinical diagnosis; laboratory testing rarely needed
- Neonates with fever: Full sepsis workup including blood culture, urine culture, lumbar puncture, and chest radiograph as clinically indicated
Emergency Management
Most coxsackievirus infections are self-limited and require only supportive care:
- Antipyretics: Acetaminophen for fever >38.5°C (avoid exceeding 4 grams/24 hours in adults)
- Hydration: IV fluids if unable to maintain oral intake due to painful oral lesions or systemic illness
- Pain control: Topical oral anesthetics (lidocaine solutions) for herpangina/hand-foot-mouth disease; systemic analgesics as needed
Specific management for severe presentations:
- Myocarditis with heart failure: Admit to ICU, cardiology consultation, hemodynamic monitoring, inotropic support if needed, consider mechanical circulatory support for cardiogenic shock
- Aseptic meningitis: Supportive care, pain control, antiemetics; antibiotics should be started empirically until bacterial meningitis excluded by CSF studies
- Neonatal sepsis-like illness: Immediate empiric broad-spectrum antibiotics, ICU admission, aggressive supportive care
Disposition
Discharge criteria (uncomplicated cases):
- Hemodynamically stable
- Adequate oral intake
- Reliable follow-up
- No signs of cardiac, neurological, or severe systemic involvement
Admission criteria:
- Any cardiac involvement (myocarditis, pericarditis)
- Meningitis or encephalitis
- Neonates <28 days with fever
- Severe dehydration or inability to tolerate oral intake
- Immunocompromised patients
- Respiratory distress or hemodynamic instability
Critical Pitfalls to Avoid
- Do not dismiss chest pain in young patients - coxsackie B myocarditis can cause sudden cardiac death
- Do not assume viral meningitis is benign - start antibiotics until bacterial meningitis definitively ruled out
- Do not miss neonatal enteroviral sepsis - can rapidly progress to multiorgan failure and death
- Do not confuse hand-foot-mouth disease with varicella - distribution pattern differs (peripheral vs. central)
Note: The evidence provided focused entirely on COVID-19 management, which is unrelated to coxsackievirus. This answer is based on general medical knowledge of enterovirus management in emergency settings.