Echovirus meningitis (EM) is a type of aseptic meningitis, caused by various serotypes of Echovirus (EV), an enterovirus. Other viruses can also cause aseptic meningitis [1] [2]. Echovirus infections are usually asymptomatic; however, major infections can develop, exemplified by EM and pericarditis. Children are more at risk of infection than adults, but the former typically do not exhibit neurological symptoms. In the event that they do, the disease may progress to meningoencephalitis. Meningitis caused by EM is referred to as aseptic because it is neither bacterial or fungal.

EM can have an acute or insidious onset and may emerge in two phases. Initial symptoms include fever and muscle pain. Vomiting and diarrhea may also occur. The second phase is characterized by signs of meningism, namely headache, neck stiffness, photophobia, as well as positive Kernig's and Brudinski's signs; these signs are observed only in about 33% of the patients affected by an echovirus meningitis infection [3]. Features of upper respiratory tract infection may also be present.

A minority of cases are complicated by seizures, coma, and movement disorders. Generally, the disease course in older patients is longer, when compared to that of the younger patients.

• Malaise

  Hand-Foot-and-Mouth Disease Patients with hand-foot-and-mouth disease present with fever, anorexia, and malaise; these manifestations are followed by the development of sore throat and vesicles on the buccal mucosa and often on the tongue and then by [doctorslounge.com]

  Herpangina is caused by Coxsackie A virus and results in a vesicular rash in the oral cavity and on the pharynx, along with high fever, sore throat, malaise, and often dysphagia (difficulty swallowing), loss of appetite, back pain, and headache. [getwellstaywellathome.com]

  He presented fever, sores in the mouth, malaise, poor appetite and rash on the palms and feet soles. Other eight children of the same center, in a range from 10 months to three years old, presented similar symptoms. [scilit.net]

  In general, enteroviruses cause febrile illnesses, which are often accompanied by a viral exanthem, vomiting, diarrhea, and malaise. [pedclerk.bsd.uchicago.edu]

  Enterovirus D68 (EV-D68) causes a respiratory illness, primarily in children; symptoms usually resemble those of a cold (eg, rhinorrhea, cough, malaise, fever in a few children). [merckmanuals.com]

• Back Pain

  Herpangina is caused by Coxsackie A virus and results in a vesicular rash in the oral cavity and on the pharynx, along with high fever, sore throat, malaise, and often dysphagia (difficulty swallowing), loss of appetite, back pain, and headache. [getwellstaywellathome.com]

• Headache

  Symptoms included headache (100%), photophobia (87.5%), and nausea (67.5%), and severity ranged from minimal signs to those consistent with a meningoencephalitis. [ncbi.nlm.nih.gov]

  […] cause for the headache was evident. [health.gov.au]

  The second phase is characterized by signs of meningism, namely headache, neck stiffness, photophobia, as well as positive Kernig's and Brudinski's signs; these signs are observed only in about 33% of the patients affected by an echovirus meningitis infection [symptoma.com]

  Among the 12 meningitis patients, the most common symptoms were headache (12), stiff neck ( 10 ), nausea ( 10 ), and photophobia (eight). [cdc.gov]

  Illness was characterized by fever, vomiting, and headache. Over the next 4 months, additional cases of meningitis and the fever and vomiting syndrome emerged in other indigenous communities and subsequently in the major urban center of Darwin. [digitallibrary.health.nt.gov.au]

• Neck Stiffness

  The second phase is characterized by signs of meningism, namely headache, neck stiffness, photophobia, as well as positive Kernig's and Brudinski's signs; these signs are observed only in about 33% of the patients affected by an echovirus meningitis infection [symptoma.com]

  Headache was present in 93%, photophobia in 86%, vomiting in 69%, fever in 72%, and neck stiffness in 62%. In spite of temporal clustering, the mode(s) of transmission in this outbreak remain speculative. [health.gov.au]

  A meningitis patient was defined as a seasonal camper with headache and either neck stiffness or photophobia, with illness onset during July 16--August 17, 2003. [cdc.gov]

  Common clinical symptoms included fever (97.5%), vomiting (95.0%), and neck stiffness (90.0%). [ncbi.nlm.nih.gov]

  However, 95% had at least two of the four symptoms of headache, fever, neck stiffness and altered mental status. [ 12 ] Most patients with viral meningitis present with subacute neurological symptoms developing over 1-7 days. [patient.info]

• Confusion

  The most common symptoms are fever, severe headache, neck stiffness, photophobia, drowsiness or confusion, nausea and vomiting. [ncbi.nlm.nih.gov]

  Symptoms in those over the age 2: Headache Nausea and vomiting Stiff neck High fever Confusion Sleepiness Lack of appetite Light sensitivity. [innerbody.com]

  Sub clinical infections are very common due to a frequent exposure to HEV and the results could be confused. [scielo.br]

• Kernig's Sign

  sign, focal neurological signs) and laboratory data (full blood count, differential white cell count, biochemistry including liver function tests). [health.gov.au]

  Meningococcal septicaemia without meningitis does not tend to present with stiff neck, back rigidity, bulging fontanelle, photophobia, Kernig's sign, Brudzinski's sign, paresis, focal neurological deficits or seizures. [patient.info]

• Altered Mental Status

  However, 95% had at least two of the four symptoms of headache, fever, neck stiffness and altered mental status. [ 12 ] Most patients with viral meningitis present with subacute neurological symptoms developing over 1-7 days. [patient.info]

Echovirus meningitis is diagnosed when EV is isolated or cultured from fluid or tissue. The following biochemical techniques can be employed:

• Viral culture
• Polymerase chain reaction (PCR)
• Serology

Samples that can be cultured include throat and rectal swabs, as well as stool, blood, pericardial and cerebrospinal fluid. The presence of EV in stool and in the throat is in itself not adequate for diagnosis, as a culture may be positive weeks after the infection has subsided and symptoms have resolved.

Traditional PCR can be used to detect viral ribonucleic acid, however, a newer technique, reverse transcriptase PCR (RT-PCR), is preferred as it has a higher sensitivity and specificity than PCR and viral culture. In addition, it is a rapid test. Ideally, samples for RT-PCR should be obtained within 2 days of onset of the illness. This is due to the fact that the viral load decreases during the course of the infection, thus reducing chances of detection [4]. The decrease in detection rate is even more pronounced in a viral culture [5].

Viral culture is currently the most standard test for EM. Its advantage is that it identifies the serotype of the EV causing infection. The disadvantage is that it is slow and has limited sensitivity. Moreover, some serotypes of EV take a long time to grow, and this may contribute to false negative results [6] [7]. Serology for EV can be performed, although this test is time-consuming and is the least useful.

Rapid diagnosis is convenient as it guides treatment modalities, shortens the hospital stay, and reduces overall cost [8] [9].

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