Enteroviruses, a group of single-stranded RNA viruses, are commonly encountered in infants and children. Coxsackie and echovirus are the main non-polio enteroviruses implicated. Widespread outbreaks are not uncommon, particularly over summer and autumn months. Neonatal sepsis and encephalitis are recognised presentations. In older children, a vague coryzl illness may be the only sequelae. Transmission of the human form is most commonly faeco-oral; respiratory and oral-oral may occur in crowded living conditions. Incubation period is 3–10 days. Infants younger than 10 days are unable to mount a significant immune response and are at higher risk of a serious infection. Overall mortality is extremely low, but greatest in those presenting with neonatal sepsis.1
From a cohort of 2544 neonates over a 20-year period, reported death rate was 11%.2
A history of a maternal febrile illness, often with gastrointestinal symptoms around the time of delivery, is commonly reported in the history. This was not a feature in our case, although one wonders of the significance of the ‘teething toddler’ at home. It is plausible that the first twin infected the second twin and that the infection had been passed on from an unknown, clinically well, source within the hospital or indeed a well-meaning visitor.
Treatment is supportive although bacterial pathogens would inevitably be treated until culture results became available. The role of aciclovir is limited, although its role in herpetic viral meningitis and encephalitis is well proven; therefore, one might argue that until herpes is disproven it is reasonable to treat as such.3
Immunity is type-specific and natural infection confers life-long immunity. Good hand hygiene is important in reducing transmission and infection control strategies for nursing infected infants include isolation and barrier nursing.4
Immunoglobulin may have a role in treatment of severe infections.5
There are case reports describing the neurological sequelae of enterovirus encephalitis in infants which is more severe than isolated meningitis. There are no recent case reports about twins acquiring the infection simultaneously in the newborn period.
This case report highlights:
- The need to always take parental concern seriously and to have a low threshold for screening the non-specifically unwell neonate for infection.
- The virulence of enterovirus between close contacts, which should be taken into account in evaluation of infants with infectious contacts.
- The greatly elevated WCC in CSF, which may result from viral meningitis (as opposed to assuming bacterial meningitis).