637 Postgrad Med J: first published as 10.1136/pgmj.28.326.637 on 1 December 1952. Downloaded from

THE COXSACKIE VIRUSES By D. GERAINT JAMES, M.B., M.R.C.P. Senior Medical Registrar, The Middlesex Hospital, W.i

Coxsackie is a village on the banks of the Hudson Epidemic Pleurodynia River in upper New York State. In the course This condition was observed in 1930 by Sylvest of investigating an outbreak of poliomyelitis there, as an epidemic of myositis occurring amongst the Dalldorf and Sickles (1948) isolated a hitherto inhabitants of fishing villages on the island of unrecognized filterable agent from the faeces of Bornholm off the coast of Denmark. It has two children with lower limb paralysis. Neu- undoubtedly occurred in earlier times, and the tralizing antibodies for this new virus appeared in original description is attributed to Finsen, who the blood of both patients during convalescence. observed it in Iceland in i856, and called it Attempts to isolate the poliomyelitis virus in pleurodynia. It has been recognized in both rhesus monkeys were unsuccessful, but paralysis epidemic and sporadic forms as an acute febrile, was induced in newborn suckling mice, although self-limiting , characterized by lower inter- not in mice over twelve days old. This discovery costal muscle or diaphragmatic pleurisy, and heralded the advent of a new family of Coxsackie occasionally accompanied by pleural friction. Its.

viruses. importance from a clinical point of view lies mainly Protected by copyright. in its differential diagnosis from tuberculous Reports soon followed of the isolation of the pleurisy, pneumonia, renal and biliary colic, Coxsackie virus in other epidemics of paralytic appendicitis, peritonitis, pulmonary infarct and poliomyelitis (Dalldorf et al., I949), in non- coronary thrombosis. paralytic poliomyelitis, or aseptic meningitis Curnen, Shaw and Melnick (I949) drew atten- (Curnen et al., I949; Melnick et al., I949); tion to a patient with epidemic pleurodynia, in pyrexia of unknown origin (Webb and Wolfe, whom the Coxsackie virus was isolated and neu- 1950); summer 'grippe' (Sabin and Steigman, tralizing antibodies to this virus were found in the I949; Melnick et al., I950), the Guillain-Barre- serum. They also mentioned three laboratory Landry syndrome (Armstrong et al., 1950), workers who were affected by pleurodynia whilst -like illnesses (Kilbourne, I950), pleuro- studying the Coxsackie virus. Findlay and Howard dynia or Bornholm disease, and herpangina. The (I950) strengthened the association between the ubiquitous nature of this virus led to a spurious Coxsackie virus and Bornholm disease still further association between it and a variety of . by reporting the occurrence of laboratory infec- More recently a cautious attitude has been adopted http://pmj.bmj.com/ in relating the Coxsackie family of viruses to tions in workers studying the virus, and also of an human disease, especially non-paralytic - interesting human transmission experiment. A and aseptic meningitis. Isolation of the volunteer was inoculated intranasally with a sus- poliomyelitis virus is a technically difficult pro- pension of the Coxsackie virus, which was known cedure, whereas the Coxsackie virus is compara- to be active in suckling mice. No symptoms tively easy to isolate. These technical points occurred until 46 hours later, when sudden pain should be borne in mind in assessing their aetio- was felt below the right scapula. It radiated

intercostally, and was aggravated by deep breath- on September 25, 2021 by guest. logical significance. Dalldorf has stated that we ing and laughing. There was a transient pyrexia are in the anomalous position of having found the of 99.z/ F., and the pain subsided after 48 hours. cause of the disease, but not the disease (Huebner Following this attack, complement-fixing anti- et al., I950). Much work has still to be done bodies for a Coxsackie virus antigen were detect- before it is possible to assess the role, if any, of able in the serum although none had been present the Coxsackie viruses in relation to the polio- before the transmission experiment. Findlay and myelitis virus and non-paralytic poliomyelitis. Howard also reported the isolation of the Coxsackie There are two clinical conditions in which all virus from the nasal washings, stools and blood of a available evidence suggests that the Coxsackie patient with Bornholm disease. virus is responsible for the disease, namely, In 1947, I I4 cases of epidemic pleurodynia epidemic pleurodynia (Bornholm disease) and were observed at the Boston City Hospital (Finn herpangina. et al., I949). Although no aetiological agent was 638 POSTGRADUATE MEDICAL JOURNAL December 1952 Postgrad Med J: first published as 10.1136/pgmj.28.326.637 on 1 December 1952. Downloaded from demonstrated at the time, fortunately some of the pain was severely aggravated by sniffing. A chest throat washings and sera were stored, and subse- X-ray revealed normal lung fields, but the right quently the Coxsackie virus was isolated from diaphragm was high and could well have been four specimens of these washings, and specific 'in spasm.' Unfortunately her clinical condition neutralizing antibodies against two strains of precluded screening at the time. viruses were demonstrated (Weller et al., I950). It was suggested that she might have a peri- It seems probable that this Coxsackie virus was tonitis due to a perforated peptic ulcer or ruptured aetiologically responsible for this Boston epidemic. appendix, or possibly an acute . Strong evidence indicating that the Coxsackie Against these diagnoses were a normal pulse and virus is aetiologically responsible for Bornholm blood pressure; rectal and vaginal examination disease and that the patient is not a mere intestinal caused no tenderness; bowel sounds were audible, carrier of this virus is afforded by some interesting a white cell count was io,6oo c.mm. with a experiments undertaken by workers at the Institut normal differential count, and the erythrocyte Pasteur (Lepine, Desse and Sautter, I952). They sedimentation rate was i i mm./hour (Westergren). were able to isolate the Coxsackie virus from During the first 24 hours in hospital her condition muscle-biopsies of two patients suffering from remained unchanged. On the second hospital Bornholm disease. Histologically, the muscle- day the pain was easier and had disappeared by biopsy sections showed the hyaline degeneration the end of the third day. The most likely diag- and mononuclear cell infiltration, just as it is seen nosis seemed to be a severe Bornholm disease. in the experimental in suckling mice. The onset with sharp pleural pain, aggravated especially by sniffing, the mild pyrexia of 99.4°, Case Report.-The following case illustrates the the high right diaphragm, and finally the benign association of Bornholm disease and the Coxsackie subsequent course were in favour of this diagnosis. virus, and also underlines its differential diagnosis Nasopharyngeal washings and faeces were from an acute abdominal catastrophe. obtained for virus isolation, and acute-phase andProtected by copyright. A 42-year-old widow was admitted to the convalescent-phase sera were examined for virus- Middlesex Hospital under the care of Dr. G. E. neutralizing antibodies. From both nasopharyn- Beaumont. Twenty-four hours before admission geal washings and faeces a Coxsackie virus of the she was walking along the promenade in Brighton B type was isolated. The acute phase serum when she was suddenly seized with severe pain revealed antibodies to a titre of i in io, and the over the right lower ribs. It was intensified by convalescent-phase serum contained neutralizing deep breathing and it radiated to the right side of antibodies to a titre of i in 500. This was a the abdomen. It passed off slowly in the course significant rise in neutralizing antibodies. of the next half hour. Four hours later it gradu- This case illustrated a more than usually ally returned and was now present in the right severe clinical picture of Bornholm disease, from loin and right iliac fossa. The severity of the it a Coxsackie virus was isolated and the blood pain prevented her from turning over in bed and' showed a significant rise in homologous neutralizing she spent a sleepless night-in considerable pain. antibodies. On the following morning she felt sick and Davies and Warin (195I) reported an epidemic http://pmj.bmj.com/ feverish. The pain was temporarily relieved by of Bornholm disease in Oxford. Patients presented I00 mg. of pethidine administered by her doctor, with thoracic or abdominal pain, or meningitic but this relief lasted only 3 hours. When it symptoms. The diagnosis should also be borne returned, she likened the pain to a ' band ' across in mind if appendicitis seems to strike a family the abdomen, aggravated by movement and deep simultaneously. breathing. Significant rises in antibody titre to the Cox-

On examination, she was lying very still in sackie virus have been found in patients who have on September 25, 2021 by guest. bed, afraid to move because of the pain. Her been diagnosed clinically as coronary thrombosis, temperature was 99.4, pulse 8o, and respira- but in which the electrocardiogram was normal tion 20. There was marked tenderness and (Findlay, 1951). rigidity over the whole abdomen, with gross rebound tenderness. However, if the hand were Herpangina allowed to rest on the abdomen, in the course of Huebner and his colleagues (1951) made aetio- i minute it would sink gradually into a softer logical studies on six children suffering from an abdomen. Bowel sounds were faintly audible, acute pharyngitis, in which small punched-out and there was no tenderness on rectal examination. ulcers with greyish bases and a surrounding red Examination of the chest revealed that the breath areola were seen on the anterior faucial pillars. sounds were slightly weaker at the right base These children also had a of short duration, posteriorly. A well-marked feature was that the and abdominal pain; several had ulcers December 1952 JAMES: The Coxsackie Viruses 639 Postgrad Med J: first published as 10.1136/pgmj.28.326.637 on 1 December 1952. Downloaded from on the hard and soft palate, and one of them on Host Range the tongue. Apart from man and infant mice, the Coxsackie Bacteriological studies were negative, but the viruses have been successfully cultivated in suck- Coxsackie virus was isolated from throat washings ling hamsters, and in tissue culture medium con- and faecal suspensions quite easily. Neutralizing sisting of minced embryonic mouse tissue (Slater antibodies against the particular strain isolated and Syverton, I950). It has been propagated with were found in a significant rising titre in con- extreme difficulty in the chick embryo, but needed valescent-phase sera. alternating mouse-egg passages (Huebner et al., Epidemiological data on a further 3I scattered I950). Cynomolgus monkeys and chimpanzees, cases revealed that it occurred in the summer; when fed with Coxsackie viruses, develop mild was probably spread by direct person to person febrile illnesset, followed by a carrier state with contact in childhood; and that the incubation neutralizing antibodies in the serum (Melnick period was about 3-5 days. and Ledinko, 1950). This subclinical infection This condition has been variously termed with an early carrier state may well represent the vesicular pharyngitis (Levine et al., I939) and usual way in which man responds to Coxsackie aphthous pharyngitis (Breese, I94I), and is infection. characterized by the appearance of small yellowish- When cockroaches are fed a single meal con- white' vesicles surrounded by a red areol& in the taining the Coxsackie group of viruses, they con- throat. Virus studies were undertaken in two of tinue to excrete virus daily for up to IS days Levine's cases and in one of Breese's series, but (Fischer and Syverton, 195I). The excreted virus were unsuccessful. The Coxsackie virus was was able to paralyse and kill infant mice, showing unknown at this time, and efforts were directed that its pathogenic properties were unaltered. towards isolation of the . Flies have been incriminated as vectors of the This had been shown (Dodd et al., 1938) to be the disease, but it seems possible that cockroaches Protected by copyright. causative agent in herpetic or aphthous may also be able to maintain and disseminate these stomatitis. viruses freely. Since the herpes simplex virus can cause vesi- Diagnosis cular stomatitis, it seems unfortunate that the term ' herpangina ' is perpetuated in association The clinical picture afforded by Bornholm with tHe Coxsackie virus. Further studies must disease when it occurs in its epidemic form is be made to determine the relative importance of sufficiently striking to enable a confident diagnosis and viruses in to be made. This disease should also be borne in the herpex simplex Coxsackie the mind in the differential diagnosis of sudden severe aetiologv of this condition. pain in the side, radiating to the abdomen, simu- lating perforation of a peptic ulcer or appehdix, The Experimental Disease biliary and renal colic, and coronary thrombosis. Infant mice are susceptible to the virus when However, the diagnosis of Coxsackie virus infec- tion cannot be inoculated intracerebrally, intraperitoneally, sub- made clinically with certainty when http://pmj.bmj.com/ cutaneously or orally. Newly-born mice or those patients present with aseptic meningitis or vesi- up to 4 days old are most susceptible. After an cular pharyngitis. The laboratory tests to confirm incubation period of 2-IO days, signs of muscular the diagnosis are (i) isolation of the virus from weakness and paralysis of the limbs appear in throat washings, blood, spinal fluid, or faeces, these suckling mice, and death ensues usually in (2) serological evidence of an immunological res- 24 hours. ponse either (a) by specific neutralizing antibodies Based on the pathological findings of the experi- to the virus isolated, or (b) by significant rises in mental disease, Dalldorf (1950) placed the many titre of the complement-fixation test. on September 25, 2021 by guest. different strains of the Coxsackie family into (i) Isolation of the virus. Routine laboratory Groups A and B. Group A infection causes diagnosis by isolation of the virus is not a practical extensive myositis with hyaline degeneration of procedure because of the complexity of the pro- the muscle fibres, oedema, and diffuse interstitial cedure, the time involved, and the numbers of mononuclear cell infiltration. Group B infection, infant mice needed. However, isolation may be in addition, causes severe encephalopathy with undertaken to establish identity of the virus in patchy neuronal degeneration, ending in cystic any given epidemic. degeneration, and also causes a peculiar necrosis of (2) (a) Neutralization test. The demonstration the interscapular fat pads. A typical Group B virus ofspecific homologous antibodies, which neutralize. was isolated from the case described above, artd the disease in test mice, is a reliable index of infec- this group is the one commonly associated with tion with a particular strain. In the case presented epidemic pleurodynia. above, the acute phase specimen of serum pro- 640 POSTGRADUATE MEDICAL JOURNAL December 1950 Postgrad Med J: first published as 10.1136/pgmj.28.326.637 on 1 December 1952. Downloaded from tected mice to a titre of i in IO, whereas the con- Treatment is, therefore, symptomatic, for the valescent phase serum protected mice to a titre of pain of Bornholm disease. Fortunately it is self- I in 500. The virus was a typical B virus, and limiting and lasts only 40-70 hours. cross-immunized with Connecticut 5 serum. (2) (b) Complement fixation test. This is the Acknowledgments most convenient method, at present, for confirmirtg I am indebted to Dr. G. E. Beaumont for per- the clinical diagnosis of Coxsackie virus infection, mission to report this case, and to the late Dr. because it can be undertaken conveniently in a hospital laboratory without recourse to animal G. M. Findlay for his help in isolating the virus. work if antigen is already provided. Five ml. clotted blood should be provided -as soon as the BIBLIOGRAPHY disease is suspected, and again after an interval of ARMSTRONG, M. P., WILSON, F. H., McLEAN, W. J. SILVERTHORNE, N., CLARK, E. M., RHODES, A. J., about io days. A significant rise in titre, at least KNOWLES, D. S., DITCHIE, R. C., and DONOHUE, four-fold in extent, between acute-phase and con- W. L. (I950), Canad. J. Pub. Health, 41, 5I. BREESE, B. B. (I941), Am. J. Dis. Child,. 6i, 669. valescent-phase sera should be the minimal criteria CURNEN, E. C., SHAW, E. W., MELNICK, J. L. (1949), J. of an immunological response on the part of the Amer. med. Ass., 14I, 894. DALLDORF, G. (i95o), Bull. N.Y. Acad. Med., 26, 329. patient. DALLDORF, G., and SICKLES, G. M. (1948), Science, Io8, 6i. Kraft and Melnick (I952) have published DALLDQRF, G., SICKLES, G. M., PLAGER, H., and GIFFORD, R. (I949), J. exp. Med., 89, 567. recently a warning against misinterpreting the DAVIES, J. B. M., and WARIN, J. F. (i9Si), Brit. med. Y., 2, 948. results of the complement-fixation test. They DODD, K., JOHNSTON, L. M., and BUDDINGH, G. J. (1938), Y. Pediat., 12, 95. observed that apart from a rise in the homologous FINDLAY, G. M. (Igsi), Personal communication. antibodies, there was frequently a significant rise FINDLAY, G. M., and HOWARD, E. M. (1950), Brit. med. 7., in titre of heterologous antibodies, although only I, I233. FINN, J. J., WELLER, T. H., and MORGAN, H. R. (1949), a single strain of the Coxsackie virus had been Arch. intern. Med., 83, 305. Protected by copyright. FINSEN, J. (I874), cited in editorial, Y. Amer. med. Ass. (1934) isolated. This could possibly be explained on the 102, 460. basis of an anamnestic reaction. It might, there- FISHER, R. G., and SYVERTON, J. T. (I9sI), Amer. Y. trop. fore, be expected that other could pro- Med., 31, 238. HUEBNER, R. J., ARMSTRONG, C., BEEMAN, E. A., and voke this non-specific antibody response, leading COLE, R. M. (I950),.7. Amer. med. Ass., I44, 609. to erroneous serological conclusions. No such HUEBNER, R. J., COLE, R. M., BEEMAN, E. A., BELL, J. A., and PEERS, J. H. (i9si), Y. Amer. med. Ass., 145, 628. non-specific response is observed when the neutra- HUEBNER, R. J., RANSOM, S. E., and BEEMAN, E.-A. (I950), lization test is performed and it gives a reliable Pubi. Hith Rep. Wash., 6s, 803. KRAFT, L. M., and MELNICK, J. L. (IgS2),.7. Immunol., 68, 297. index of homologous antibodies only. KILBOURNE, E. D. (I9so), Fed. Proc., 9, s8i. LEPINE, P., DESSE, G., SAUTTER, V. (I952), Bull. Acad. Med. Paris, 136, 66. Treatment LEVINE H. D., HOERR, S. O., and ALLANSON, J. C. (1939), Y. Amer. med. Ass., 112, 2020. The Coxsackie viruses are resistant to penicillin, MELNICK, J. L. (I950), Bull. N.Y. Acad. Med., 26, 342. streptomycin, aureomycin, terramycin and chlor- MELNICK, J. L., and LEDINKO, N. (I950),.7. Immunol., 64, 101. MELNICK, J. L., LEDINKO, N., KAPLAN, A. S., and KRAFT. amphenicol. This lack of response to antibiotics L. M. (I95o),.7. exp. Med., 91, I85s is a feature in common with most other viruses. MELNICK, J. L., SHAW, E. W., and CURNEN, E. C. (949), http://pmj.bmj.com/ The newer antibiotics are only effective against Proc. Soc. exp. Biol. N.Y., 71, 344. SABIN, A. B., and STEIGMAN, A. J. (949), Amer..7. Hyg., 49, the large viruses of the lymphogranuloma-psitta- 176. ' SLATER, E. A., and SYVERTON, J. T. (195o), Proc. Soc. exper. cosis group and the unknown agent of primary Biol. N.Y., 74, 509. atypical pneumonia', whereas the Coxsackie SYLVEST, E. (1930), Ugeshr. Laeg., 92, 982. (Translated by Andersen, H., 1934, Epidemic , Oxford University viruses are probably of small size. In our present Press.) state of imperfect knowledge of the mode of action WEBB, C. H., and WOLFE, S. G. (i9So), Am. Y. Dis. Child., 80, of antibiotics on the size of the virus is a 245.

viruses, on September 25, 2021 by guest. WELLER, T. H., ENDERS, J. F., BUCKINGHAM, M., and rough index of its response to antibiotics. FINN, J. J., Jr. (095o), Y. Immunol., 6s, 337.

CORRIGENDUM " Textbook of Surgical Treatment," Edited by C. F. W. Illingworth. The review of this book in November mentioned that "Professor Dick has recruited, etc." This should have been " Professor Illingworth, etc." We apologise.