Dec.

, 1950

The Coxsackie Viruses*

GILBERT DALLDORF, M.D., F.A.P.H.A.
Division of Laboratories and Research, New York State Department of Health,
Albany, N. Y.
SINCE the Coxsackie viruses were case of poliomyelitis, the throat wash-
discovered three years ago 1-3 they ings are less suitable after the first days
have been shown to be common human of illness than the feces-that the virus
infections, but their importance as a persists in the patient's stools for a
cause of disease and disability is still longer period of time. I suspect that the
uncertain. We cannot hope to measure same may be true of the Coxsackie
their importance until additional cases viruses. It is interesting in this regard
and outbreaks have been carefully to note that, of the hundreds of fecal
studied, and this requires the coopera- specimens we have tested in mice, we
tion of competent virologists for at the have found no other viruses than mem-
moment a certain diagnosis can only be bers of the Coxsackie group. Throat
made in the laboratory. Pathognomonic washings will now and then yield another
clinical signs and lesions have not yet agent. Recently, for example, a litter
been discovered. of suckling mice injected with a sus-
The Coxsackie viruses have usually pension of throat washings came down
been found in the feces or throat wash- with herpes simplex infection. Feces
ings of patients or individuals recently from the same patient yielded neither
ill or in close contact with a sick person. virus.
There are reports of an occasional iso- The type of illness associated with
lation from the blood stream or cerebro- Coxsackie virus infection is quite varied.
spinal fluid but I doubt that either kind Our own experience has been largely
of specimen is a promising place to look based on a search for Coxsackie viruses
for virus. In our own experience, we in the feces of patients with poliomye-
have never recovered virus from speci- litis or with symptoms similar to those
mens of cerebrospinal fluid and the only of poliomyelitis. Coxsackie virus may
time virus was recovered from blood is frequently be found in such cases. Some-
open to suspicion since the tube was times both agents, poliomyelitis and
cracked when received and the specimen Coxsackie viruses, are simultaneously
could have been contaminated. present. When we recently reviewed the
The choice between throat washings work of the past three years,4 we found
and feces may not be important. It has that we had isolated Coxsackie viruses as
been our practice to examine feces, but frequently from paralyzed as from non-
this summer throat washings are also paralyzed patients. On the other hand,
being tested and it may eventually be an outbreak in Connecticut in 1948
possible to determine which specimen is seems to have been exclusively non-para-
preferable. You will recall that, in the lytic.5 Others 6'7 have isolated Cox-
sackie virus from patients with a variety
* Presented before the Laboratory Section of the of symptoms. A recent
British report8
American Public Health Association at the Seventy- suggests that the Coxsackie viruses have
eighth Annual Meeting in St. Louis, Mo., November something to do with epidemic pleuro-
1, 1930.
[1508s
Vol 4 COXSACKIE VIRUSES
dynia or Bornholm disease, and I under-
stand more definite evidence is soon to
be reported from Boston.9 It would be
unwise at this time to restrict one's
search for Coxsackie viruses to a par-
ticular illness and indeed there is ample
justification for looking far afield.
The identification of Coxsackie viruses
is based on two of their characteristics.
The first of these is that they are patho-
genic only for suckling mice and ham-
sters-not for weaned ones. Some of the
strains of Coxsackie virus are at least
infective for monkeys and chimpanzees
and all are presumably pathogenic for
man but, of the small laboratory animals,
only the new-born and immature ones
are susceptible. The second character-
istic is the experimental disease. An
agent that causes illness and death only
in immature mice and that induces
certain lesions may, be tentatively identi-
fied as a member of the Coxsackie group.
The lesions are essential in identifying
the virus and in classifying the various
strains. It is usually simple by histo-
logic examination to determine whether
a particular strain belongs in Group A or
Group B. The Group A viruses cause
widespread degeneration of the striated
muscles. Few muscle bundles are
spared. The mice die promptly, follow-
ing paralysis and weakness. Lesions are
not found elsewhere. The Group B mice
have focal muscle lesions, sometimes
found only after rather thorough search.
In addition, mice infected with Group
B strains will be found to have charac-
teristic and severe lesions of the brain,
the fat pads, or both. The mice may
show spasms or paralysis or both for a
number of days. All of the strains that
have been -isolated in our laboratories
may be classified by these means. As is
evident, such a classification simplifies
the final serologic identification of a new
strain by restricting comparison to mem-
bers of one of the groups.
The Coxsackie viruses are rather nu-
merous. Within our own experience,
1509
nine serologic types have been tenta-
tively identified. Other workers have
reported strains that may represent addi-
tional types. The multiplicity of types
is, of course, a severe handicap to the
use of serologic tests for clinical diag-
nosis. To us, it seems more practical to
identify cases by isolating virus rather
than by serologic means. Once a virus
has been isolated, it is, of course, im-
portant that the acute and convalescent
sera of the patient from whom it was
obtained be tested against it to demon-
strate a rise in antibodies. This may be
done by means of neutralization or
complement-fixation tests. Both methods
may also be used in comparing strains of
virus,10 11 and Melnick has cleverly
adapted the cross-protection test to the
same purpose, using infant mice born of
vaccinated mothers.12 This is necessary,
of course, because by the time new-born
-mice can be immunized they have be-
come spontaneously immune to infection.
All three methods usually give clear-cut
results although we have some evidence
that cross-relationships may exist be-
tween certain types at present under
investigation. By and large, the serologic
comparison of strains is straightforward
and satisfactory but the study of human
sera is often less clear-cut.
Recognizing the multiplicity of strains
and the value of histologic classification,
we have used a scheme of identification
by which the various types are num-
bered. Miss Sickles and I 11 originally re-
ported Types 1, 2, and 3 of Group A and
some time later described the criteria
by which Group B may be recognized.8
Miss Howitt 13 has added Types 4 and
5 to Group A and three additional Group
A types have since been assigned num-
bers in Albany. Moreover, a second
serologic type of Group B virus is now
available. This method of identification
has much to recommend it. Geographic
names are of little significance. The
same type of virus has been found in
various parts of this country and in other
1510 AMERICAN JOURNAL OF PUBLIC HEALTH
countries. A uniform terminology is
badly needed, since the use of various
geographic names or patients' initials for
the same type of virus is bound to be
confusing. It would seem to be the
responsibility of all investigators to com-
pare their own strains with the estab-
lished ones and to follow a consistent
system of classification. This may be
of considerable importance in evaluating
the clinical significance of the various
members of the Coxsackie groups.
It is evident from published re-
ports that a surprisingly large number
of laboratory infections have already oc-
curred.8, 14 This should caution us to
exercise the greatest possible care in
protecting laboratory personnel and also
in avoiding cross-infection among suck-
ling mice. The routine we are using is
as exacting as circumstances permit.
Newly isolated strains are maintained in
separate rooms until ample specimens
have been accumulated. Frequently
strains are retested with known sera.
Individual pans for examining mice, indi-
vidual forceps for handling them, and
similar precautions are carefully fol-
lowed. Being conscious of the dangers
of cross-infection, it has been our prac-
tice to use infected mouse brain, rather
than the carcasses of mice, as sources of
virus. We have done this chiefly because
the brain can be harvested with less
risk of contamination than the carcass.
Coxsackie viruses are stable, resem-
bling poliomyelitis virus rather closely
in this respect. Infected mouse brains
may be preserved for years in 50 per cent
glycerol or at -700C. and suspensions
are quite stable even at room tempera-
ture. The virus is not readily inacti-
vated by heat, and is little affected by a
rather wide pH range. These viruses are
excellent antigens and specific sera of
high titer may be readily produced in
experimental animals.
In all these respects, the Coxsackie
viruses are very satisfactory laboratory
tools. Indeed the greatest practical dif-
Dec., 1950
ficulty they present is the necessity for
an ample supply of immature mice. Since
the mother must also be sacrificed, the
inroads into the breeding colony are
serious. We have learned several little
tricks that are helpful when using suck-
ling mice. The mothers must be watched
to make sure they are interested in the
young. If they are not, a new mother
may be supplied and sometimes the
litter saved. It is not difficult to see
when the young are being well fed. We
have made a practice of handling the
test animals randomly. All the young
to be used on a particular day are pooled
and distributed to individual cages and
mothers by random sampling.15 This
sometimes saves an experiment, for lit-
ters vary considerably. We prefer to
use mice not less than 2 days or more
than 4 days of age. Younger animals are
more delicate and it is more difficult to
interpret their clinical behavior.
There are indeed no special or very
serious obstacles to the study of the
Coxsackie viruses and much remains to
be learned about them. They seem to
be especially intriguing because they
resemble in many respects poliomyelitis.
Possibly, Coxsackie virus infection will
prove to be an ecologic model of polio-
myelitis and so open to many workers
the opportunity of studying that serious
disease.
REFERENCES
1. Dalldorf, Gilbert, and Sickles, G. M. An Uni-
dentified, Filtrable Agent Isolated from the Feces of
Children with Paralysis. Science 108:61-62, 1948.
2. Dalldorf, Gilbert, Sickles, G. M., Plager, Hildegard,
and Gifford, Rebecca. A Virus Recovered from the
Feces of "Poliomyelitis" Patients Pathogenic for
Suckling Mice. J. Exper. Med. 89:S67-582, 1949.
3. Dalldorf, Gilbert. The Coxsackie Viruses. Bull.
New York Acad. Med. 26:329-335, 1950.
4. Dalldorf, Gilbert, and Gifford, Rebecca. Clinical
and Epidemiologic Observations of. Coxsackie Virus
Infection. To be published.
5. Curnen, E. C. Human Disease Associated with the
Coxsackie Viruses. Bull. New York Acad. Med.
26:335-342, 1950.
6. Howitt, B. F. Recovery of the Coxsackie Group
of Viruses from Human Sources. Proc. Soc. Exper.
Biol. & Med. 73:443-448, 1950.
7. Kilbourne, E. D. Diverse Manifestations of In-
fection with a Strain of Coxsackie Virus. Federa-
tion Proc. 9:581-584, 19S0.
8. Findlay, G. M., and Howard, E. M. Coxsackie
Vol.40 COXSACKIE VIRUSES
Viruses and Bornholm Disease. Brit. M. 1. 1:
1233-1236, 1950.
9. Weller, T. H. Personal communication, June 15,
1950.
Weller, T. H., Enders, J. P., Buckingham, M., and
Finn, J. J., Jr. The Etiology of Epidemic
Pleurodynia: A Study of Two Viruses Isolated from
a Typical Outbreak. J. Immunol. 65:337-346,
1950.
10. Casals, Jordi, and Olitsky, P. K. Complement-
fixation Tests with Some of the Viruses in the
Coxsackie Group. Federation Proc. 9:570-573,
1950.
11. Sickles, G. M., and Dalldorf, Gilbert. Serologic
Differences Among Strains of the Coxsackie Group
of Viruses. Proc. Soc. Exper. Biol. & Med. 72:
30-31. 1949.
Kellogg Foundation Grants
An important new project has been
undertaken by the W. K. Kellogg Foun-
dation,- Battle Creek, Mich., which
" aims to improve the quality of ad-
ministration in public school systems."
Funds will go to certain universities to
-enable their schools of education to
develop programs of on-the-job educa-
tion for local community and state school
-administrators. The University of Chi-
cago, Harvard University, and Teachers
College, Columbia University have re-
ceived grants in excess of $200,000 each
and the Foundation estimates that the
grants for this project over a 5 year
period may reach $3,000,000.
Three new projects in the field of
-dental education were also announced,
Awo of them 3 year grants. These went
1511
12. Melnick, J. L. Studies on Coxsackie Viruses:
Properties, Immunological Aspects and Distribu-
tion in Nature. Bull. New York Acad. Med. 26:
342-356, 1950.
13. Howitt, B. F., and Benefield, U. R. Use of
Complement-fixation in the Differentiation of
Strains of Coxsackie Virus. Proc. Soc. Exper.
Biol. & Med. 73:90-92, 1950.
14. Shaw, E. W., Melnick, J. L., and Curnen, E. C.
Infection of Laboratory Workers with a Virus
Pathogenic for Infant Mice. Ann. Int. Med. 33:
32-40, 1950.
15. Wadsworth, A. B. Standard Methods of the
Division of Laboratories and Research of the New
York State Department of Health (3d ed.), Balti-
more: Williams & Wilkins, 1947, p. 146.
to the University of Detroit in the
amount of $66,500 for the training of
dental hygienists in a 2 year course and
a smaller grant went to the Chnadian
Dental Association for a survey of
Canadian dental schools. Three visiting
professorships in Latin American uni-
versities to be filled by faculty members
from dental schools in the United States
were approved.
The Massachusetts Department of
Public Health received a grant in excess
of $140,000 over a 5 year period for
field training of public health personnel.
The Oregon State Health Department
received more than $82,000 for the
development of a program of sight con-
servation. Other smaller grants went to
community health projects in Michigan.