Overview of Coxsackievirus Infections

A father checking his daughter for a fever

Rebecca Nelson / Getty Images

Next to norovirus, the coxsackievirus is probably one of the most common viruses that you have never heard of. First discovered in the 1940s, it is a type of non-polio enterovirus. This group of viruses also includes echoviruses and other enteroviruses (one of which, enterovirus D68, caused a nationwide outbreak of respiratory infections in the United States that was associated with acute flaccid paralysis).

While you might not be familiar with coxsackievirus, though, if you have a child there is a good chance that you do know about the infection and how one of its strains causes hand, foot, and mouth disease (HFMD). It's a common viral infection of early childhood, caused by coxsackievirus A16.

Altogether, there are 29 serotypes of coxsackievirus that can cause infections in people, including:

  • Coxsackievirus A2-8, A10, A12, A14, A16 (a type of Human enterovirus A)
  • Coxsackievirus A9 (a type of Human enterovirus B)
  • Coxsackievirus B1-6 (a type of Human enterovirus B)
  • Coxsackievirus A1, A11, A13, A17, A19-22, A24 (a type of Human enterovirus C)

Since it was first identified in 2008, coxsackievirus A6 has been causing more severe and atypical cases of HFMD in the United States and worldwide, including in adults.

Different Coxsackievirus Infections

Again, HFMD, with ulcers in a child's mouth and blisters on their hands and feet, is typically the most well-known infection caused by the coxsackievirus, but coxsackievirus is also associated with:

  • Congenital Infections: infections in pregnancy that spread to the fetus
  • Neonatal Infections: rare, but can cause bleeding problems, hepatitis, meningitis, meningoencephalitis, myocarditis, and sepsis, etc., and is highlighted by a nationwide outbreak of coxsackievirus B1 infections in 2007
  • Acute Hemorrhagic Conjunctivitis: Coxsackievirus A24 can cause outbreaks of a pink eye with subconjunctival hemorrhages
  • Gastrointestinal Disease: Coxsackievirus can cause hepatitis, nonbacterial diarrhea, or gastroenteritis, and HUS.
  • Herpangina: similar to HFMD, with oral ulcers, but without a rash or blisters on the child's hands or feet
  • Meningitis
  • Myopericarditis: inflammation and damage to the heart muscle and sac surrounding the heart, which can be caused by coxsackievirus B1, B2, and B5 infections
  • Myositis: inflammation of a muscle, which can be caused by coxsackievirus infections
  • Petechial and Purpuric Rashes: especially with coxsackievirus A9, which could get confused with Henoch-Schonlein purpura (HSP)
  • Pleurodynia: sudden onset of chest pain caused by inflammation of the diaphragm and linked to a coxsackievirus infection
  • Respiratory Illnesses: usually with a mild cough, runny nose, and sore throat and can be caused by coxsackievirus A21 and A24.

The coxsackievirus can also cause nonspecific febrile illnesses and a roseola-like illness—fever for two to three days followed by a rash for one to five days.

Surprisingly, the great majority of people with coxsackievirus infections have no symptoms at all, and there is no vaccine, cure, or treatment for coxsackievirus infections besides supportive care and treating symptoms. That sounds alarming, but fortunately, the most common coxsackievirus infections are not serious.

Getting and Avoiding Coxsackievirus Infections

Children can get sick about three to six days after being exposed to someone with a coxsackievirus infection (the incubation period). How do they get this virus?

Like many viral infections, the coxsackievirus is spread by both fecal-oral (direct or indirect contact with stool) and respiratory transmission (someone coughs or sneezes on you). They can also get these infections by touching a contaminated object (fomite).

For example, the CDC states that you might get infected by kissing someone who has the hand, foot, and mouth disease or by touching a doorknob that has viruses on it, then touching your eyes, mouth, or nose.

Still, because kids can shed the coxsackievirus in their stool and respiratory tract secretions (saliva and nasal secretions) for weeks after their symptoms have gone away or even without any symptoms, outbreaks can be hard to control or avoid.

That's probably why there are not strict guidelines to keep kids out of school and daycare when they have HFMD. For example the CDC states that "children should stay home while they have symptoms of hand, foot, and mouth disease" but they could still be shedding the virus. And in Texas, the Department of State Health Services says that kids with HFMD can go to school and daycare as long as they don't have a fever.

Regardless, handwashing, avoiding respiratory secretions, and disinfecting contaminated surfaces is more important than ever to help avoid getting sick and spreading these infections.

Facts to Know About Coxsackievirus

Other things to know about coxsackievirus infections include:

  • Other countries sometimes see more severe cases of HFMD, often caused by enterovirus 71.
  • Although complications from HFMD are rare, if you are pregnant and think you may have been exposed, the CDC recommends that you contact your health care provider.
  • Studies have indicated that type 1 diabetes may be linked to previous coxsackievirus type B infections.
  • Skin peeling on hands and feet and nail dystrophies can occur after coxsackievirus infections, especially coxsackievirus A6. The nail dystrophy ranges from developing Beau's lines (deep, horizontal grooves in a child's nails), nail breakage, to actually losing one or more nails and occurs one to two months after the primary infection.
  • Testing can be done for most types of coxsackievirus, including by reverse transcriptase-polymerase chain reaction (PCR) assay and culture, but it is not something that can be routinely or quickly done in a pediatrician's office. It is typically not necessary either.
  • Outbreaks of some coxsackievirus infections tend to occur in three to five-year cycles, while others circulate at low levels each year, especially in tropical climates. In other parts of the world, including the U.S., coxsackievirus infections are more common in summer and fall months.
  • Having an infection with one coxsackievirus serotype doesn't give you immunity to any of the others, so you can, and likely will, get coxsackievirus infections multiple times in your life. Cross-reactivity between serotypes might offer some protection, though.
Was this page helpful?

Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Lee CJ, Huang YC, Yang S, et al. Clinical features of coxsackievirus A4, B3 and B4 infections in children. PLoS ONE. 2014;9(2):e87391. doi:10.1371/journal.pone.0087391

  2. Sun J, Hu XY, Yu XF. Current understanding of human enterovirus D68. Viruses. 2019;11(6):490. doi:10.3390/v11060490

  3. Centers for Disease Control and Prevention. Hand, foot, and mouth disease: causes and transmission. Updated December 6, 2019.

  4. Brooks David Kimmis MD, Downing C, Tyring S. Hand-foot-and-mouth disease caused by coxsackievirus A6 on the rise. Cutis. 2018;102:353-356.

  5. Zuo J, Quinn KK, Kye S, Cooper P, Damoiseaux R, Krogstad P. Fluoxetine is a potent inhibitor of coxsackievirus replication. Antimicrob Agents Chemother. 2012;56(9):4838-4844. doi:10.1128/AAC.00983-12

  6. Langford MP, Anders EA, Burch MA. Acute hemorrhagic conjunctivitis: anti-coxsackievirus A24 variant secretory immunoglobulin A in acute and convalescent tear. Clin Ophthalmol. 2015;9:1665-1673. doi:10.2147/OPTH.S85358

  7. Gaaloul I, Riabi S, Harrath R, et al. Coxsackievirus B detection in cases of myocarditis, myopericarditis, pericarditis and dilated cardiomyopathy in hospitalized patients. Mol Med Rep. 2014;10(6):2811-2818. doi:10.3892/mmr.2014.2578

  8. Royston L, Tapparel C. Rhinoviruses and respiratory enteroviruses: not as simple as ABC. Viruses. 2016;8(1). doi:10.3390/v8010016

  9. Kang JH. Febrile illness with skin rashes. Infect Chemother. 2015;47(3):155-166. doi:10.3947/ic.2015.47.3.155

  10. New York State Department of Health. Hand, foot and mouth disease (Coxsackie viral infection). Updated October 2011.

  11. Texas Department of State Health Services. Communicable Disease Chart and Notes for Schools and Child-Care Centers. Updated March 2013.

  12. Sabanathan S, Tan Le V, Thwaites L, Wills B, Qui PT, Rogier van Doorn H. Enterovirus 71 related severe hand, foot and mouth disease outbreaks in South-East Asia: current situation and ongoing challenges. J Epidemiol Community Health. 2014;68(6):500-502. doi:10.1136/jech-2014-203836

  13. Centers for Disease Control and Prevention. Complications of hand, foot, and mouth disease. Updated December 6, 2019.

  14. Hyöty H, Leon F, Knip M. Developing a vaccine for type 1 diabetes by targeting coxsackievirus B. Expert Rev Vaccines. 2018;17(12):1071-1083. doi:10.1080/14760584.2018.1548281

  15. Shin JY, Cho BK, Park HJ. A clinical study of nail changes occurring secondary to hand-foot-mouth disease: onychomadesis and Beau's lines. Ann Dermatol. 2014;26(2):280-283. doi:10.5021/ad.2014.26.2.280

  16. Centers for Disease Control and Prevention. Non-polio enterovirus: outbreaks and surveillance. Updated November 14, 2018.

  17. Centers for Disease Control and Prevention. Hand, foot, and mouth disease. Updated July 15, 2019.

Additional Reading

  • Increased Detections and Severe Neonatal Disease Associated with Coxsackievirus B1 Infection. United States. 2007. MMWR. May 23, 2008 / 57(20);553-556.
  • Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Eighth Edition.
  • McIntyre MG, et al. Notes from the Field: Severe Hand, Foot, and Mouth Disease Associated with Coxsackievirus A6 — Alabama, Connecticut, California, and Nevada, November 2011–February 2012. MMWR. March 30, 2012 / 61(12);213-214.
  • Oberste MS, Gerber SI. Enteroviruses and parechoviruses. 2014. In: Viral Infections in Humans, 5th ed.; Kaslow RA, Stanberry LR, LeDuc JW, eds. Springer, New York; pp 225-252.
  • Red Book: 2015 Report of the Committee on Infectious Diseases. Pickering LK, ed. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
  • Stewart, et al. Coxsackievirus A6–Induced Hand-Foot-Mouth Disease. JAMA Dermatol. 2013;149(12):1419-1421.