Letter to the Editor Generalized infection associated with ECHO virus Maria Dalamaga a,b , Konstantinos Karmaniolas a, * , Charilaos Chavelas c , Stavros Liatis a Helen Matekovits a , Ilias Migdalis a a Department of Internal Medicine, NIMTS General Hospital, Monis Petraki 12, 69-71, Souidias Street, T.K. GR-115 21 Athens, Greece b Department of Clinical Microbiology, NIMTS General Hospital, Monis Petraki 12, T.K. GR-115 21 Athens, Greece c Department of Dermatology, University Hospital of Ioannina, T.K. GR-451 10 Ioannina, Greece Received 29 April 2003; received in revised form 16 September 2003; accepted 9 October 2003 Keywords: Exanthem; Meningitis; Hepatitis; Myocarditis; Pancreatitis; ECHO virus A 40-year-old Caucasian woman was admitted to our hospital with high fever, intense frontal headache, multiple episodes of vomiting, rash, and myalgias that had started 2 days prior to her admission. Physical examination revealed a blood pressure of 130/80 mmHg and a body temperature of 39.5 jC. Nuchal rigidity, conjunctival suffusion, oral ulcerations, and pharyngeal injection were present. Labo- ratory examination revealed a white blood cell count of 13,900 per mm 3 (60% lymphocytes), AST 189 U/l, ALT 205 U/l, and g-GT 100 U/l. CSF analysis showed 204 white blood cells/mm 3 (80% of which were lymphocytes and mononuclear cells), protein 72 mg/dl, and glucose 54 mg/dl. An electrocardiogram revealed the presence of non- specific ST-T wave changes with a normal sinus rhythm. Echocardiography showed a reduced ejection fraction (29%). Three days after admission, the patient was afebrile but she experienced acute mid-epigastric pain and multiple episodes of vomiting. Laboratory evaluation was remark- able due to a markedly elevated serum amylase 3850 U/l, lipase > 40,000 U/l, and urine amylase >8000 U/l. A CT scan of the abdomen revealed a diffuse thickening of the pancreas that was consistent with pancreatitis. Enteroviral RNA from CSF and rectal specimens was detected by RT- PCR. The serum neutralizing antibody to ECHO virus 9 rose from 1/4 on admission to 1/32 some 2 months later, while the specimens were tested in series. ECHO viruses have been associated with a wide range of clinical syndromes affecting many organ systems that in- clude febrile illnesses, exanthems, aseptic meningitis and encephalitis, neonatal infections, respiratory disease, and gastroenteritis [1,2]. Very rarely has ECHO virus infection been associated with hepatitis [1,3] or pancreatitis [4]. ECHO virus type 9 has only rarely been documented as the cause of myocarditis [5]. In conclusion, we believe that cardiac, hepatic, and pancreatic abnormalities should be considered in the spec- trum of diseases caused by ECHO virus infection, especially when they are associated with febrile exanthematous illness and/or aseptic meningitis in the setting of a rising ECHO virus antibody titer and/or the isolation of enteroviral genome from CSF or other clinical specimens. References [1] Melnick JL. Enteroviruses: polioviruses, coxsackieviruses, echovi- ruses, and newer enteroviruses. In: Fields BN, Knipe DM, Howle PM, editors. Fields virology. 3rd ed. Philadelphia: Lipincott-Raven; 1996. p. 655 – 711. [2] Gondo K, Kusuhara K, Take H, Ueda K. Echovirus type 9 epidemic in Kagoshima, southern Japan: seroepidemiology and clinical observation of aseptic meningitis. Pediatr Infect Dis J 1995;14:787 – 91. [3] Scleissner LA, Portnoy B. Hepatitis and pneumonia associated with ECHOvirus, type 9, infection in two adult siblings. Ann Intern Med 1968;68:1315 – 9. [4] Arnesjo B, Eden T, Ihse I, Nordenfelt E, Ursing B. Enterovirus infec- tions in acute pancreatitis—a possible etiological connection. Scand J Gastroenterol 1976;11:645 – 9. [5] Monif GR, Lee CW, Hsiung GD. Isolated myocarditis with recovery of ECHO type 9 virus from the myocardium. New Engl J Med 1967;277: 1353 – 5. 0953-6205/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2003.10.005 * Corresponding author. Tel.: +30-210-725-2784; fax: +30-210-729- 3706. E-mail address: dalamaga-chavelas@ath.forthnet.gr (K. Karmaniolas). www.elsevier.com/locate/ejim European Journal of Internal Medicine 15 (2004) 68