Coxsackie: is it serious?

When your doctor told you that your child has “coxsackie”, most of you will be very worry. Your friends and relatives who get to know this will do whatever they can to avoid contact with your pity child. Perhaps the news about the coxsackie outbreak which took away a few precious lives still lingering in your mind. Is coxsackie infection really so serious? Though it can be serious, but 99.99% of the time, it's NOT.

Coxscakievirus infection is very common, it occurs everyday in tropical country. About 90% of the time, you don't even know that you are actually infected with this virus because it produces only flu-like symptoms and sometimes no symptoms at all. Hundreds of viruses can cause flu-like symptoms (fever, cough, runny nose, sore throat). Doctors are unable to diagnose coxsackievirus infection unless he takes swab from your oral or rectum and send for coxsackievirus test. There is no blisters in the mouth or on the hands or feet whatsoever.

For the rest of 10% of time, coxsackievirus infection will show more specific signs in which we can classify them into a specific disease. Hand-foot-mouth disease, which we are most familiar with, is one of them. It will be more serious if it shows signs of brain (meningitis/encephalitis) or heart involvement. However, involvement of brain & heart is extremely rare, and unlikely to end up in death with prompt treatment.

    Coxsackievirus

So when you hear someone has “coxsackie”, then he/she most probably has hand-foot-mouth disease. Since coxsackievirus is an enterovirus (entero=gut), it is transmitted through fecal-oral route, when the stool of the infected child somehow land in your mouth! Other than this, the oral/nasal secretion and blister fluid also contain the virus . Thus coxsackievirus also can be spread through direct contact with this secretion. For example, when the infected child touch his stool or rub his watery nose, then he touch a toy, then another child touch that toy and put his unwashed hands in his mouth or nose. Besides, the virus can also fly in the air when sneezing or coughing and land in others' nose or mouth.

Coxsakievirus is highly contagious, so it's not uncommon to see small “outbreak” within nursery or kindergarten. Infants are more likely to get it and the risk decreases with age and it's not common in children >10 years old and adult. For hand-foot-mouth disease, the illness usually last 5-7 days, and the child are most contagious for this period of time. So, usually doctors will suggest to avoid contact with the affected child for at least 1 week.

The rash of hand-foot-mouth disease typically start with red dots, which turn into blisters and then later ulcers. It appears on the hands (palm), feet (sole) and mouth (tongue, gum, palate, inner cheek). The rash has a characteristic erythemathous halo (red ring around the blisters). It may last for 5-10 days. Sometimes the blisters only affect the mouth but not the hands or feet (herpangina).

    Blisters/ulcers with typical "red ring" around them

There is no specific treatment for coxsackievirus infection or hand-foot-mouth disease. It can get cured by our own immune system in 7-10 days. Since blisters or ulcers in the mouth can be painful, some infants or small children may have poor feeding which can lead to dehydration (lack of fluids). If this happen, it may warrant hospital admission for intravenous fluid replacement. Medicine usually given are to relieve fever and pain in the mouth.

Coxsackievirus or hand-foot-mouth disease is a mild disease. So, don't be panic.

URTI: Do You Need Antibiotic?

Upper respiratory tract infection (URTI) refers to infection of the upper airway, which include the nose, sinus, throat (pharynx), vocal cord area (larynx) and trachea. It causes symptoms such as running nose, cough, sore throat, fever etc. Generally speaking, it is caused by either virus or bacteria. Viral URTI is self-limiting, or in another words, can cure by itself without specific treatment. Bacterial URTI, most common by streptococcus, requires antibiotic treatment to prevent very rare but serious complication which can affect the heart and kidneys.

Can a doctor differentiate between a viral and bacterial URTI? It’s important to do so but it’s difficult because the signs and symptoms they produce often overlap each other. When a doctor sees a patient with URTI symptoms, streptococcus bacteria infection and pneumonia (lungs infection) are what he/she wants to rule out. What are the clues doctors look for? Streptococcus bacteria URTI affect the throat (pharyngitis), more commonly in children age 5-15 years old, so the main symptom is sore throat. As the nose and larynx are not involved, usually there are no running nose and cough. Some people may think that thick greenish phlegm suggests bacteria infection but this is not true. Even virus infection can produce yellow or green phlegm.

Doctors will check your temperature, as streptococcal URTI usually causes high grade fever (>38.5 C). However, please bear in mind that some viral infection can cause high fever as well. Then doctors will look at your throat to see whether the tonsils are inflamed or enlarged. Both virus and bacteria can cause enlarged tonsils but when there are exudates (white patches) on the tonsils, it makes bacteria infection more likely. Doctors will also look for skin rash and palpate your neck to feel for enlarged lymph nodes. Lastly, doctors will use a stethoscope to listen to your lungs to make sure that your lungs are not involved. In summary, you probably need antibiotic if you have high fever with sore throat, little or no cough nor running nose, has inflamed throat/tonsils with exudates and enlarged neck lymph nodes >1cm.

    Tonsils with exudates   

Virus URTI does not require anti-viral unless in some special situation like new strain AH1N1. Of course antibiotic has no effect in any viral infection. So, if you do not fit into the scenario of streptococcus bacteria infection as described above, then most probably you do not need to worry much. There are hundreds of different viruses which can cause URTI. Common cold, which produces mainly nose symptoms (running nose, nose congestion/block, sneezing), watery eyes, sometimes sore throat and mild cough, is caused by virus. Adults with common cold usually do not even have any fever. Influenza (flu), which is also a virus infection, makes you extremely tired with pain all over the body besides giving you high fever, cough & some stuffy nose. When getting flu, you may think that you are having a serious infection, but actually you don't need antibiotic at all.

No matter what virus it is, it is not so important because the treatment is the same – rest and plenty of fluids. Doctors may give some medicine to relieve the fever, stuffy nose, cough and sore throat. However, you are not going to shorten the duration of the infection by taking these medicines. Viral URTI can last for 3-14 days. The average I would say is 7 days. Usually the symptoms will get better after 3 days. If the symptoms last more than 2 weeks or get progressively worse, the diagnosis of simple viral URTI need to be revised. This situation can be caused by bacteria superinfection, in which bacteria infects the part initially infected by a virus. As a rule of thumb, only about 10% of URTI are caused by bacteria. So, next time when you have fever, runny nose, cough, sore throat etc, give at least 7 days to your body immune system to work and don’t always ask for antibiotics. Antibiotics have side effects, they kill your friendly bacteria and contribute to produce antibiotics-resistant superbugs.

When you actually have a bacteria URTI, will you get better without antibiotic? Yes, you can. Your body immune system will eventually beat the invading bacteria, but it may take longer time. Children with untreated streptococcus URTI have a very small but significant risk of getting complication after the URTI has cured, such as rheumatic fever and glomerulonephritis. Do you need to see a doctor for URTI symptoms? Well, if you are worry, then just go and see one.