Co-infection with coxsackievirus A5 and norovirus GII.4 could have been the trigger the first episode of a severe encephalopathy in a six-year-old child with the intermittent form of maple syrup urine disease (MSUD)

In this case study, a coxsackievirus A5 (Picornaviridae) and a norovirus GII.4 (Caliciviridae) co-infection were detected using RT-PCR from a faecal sample of a 6-year-old girl with symptoms of severe acute encephalopathy subsequently diagnosed as intermittent form of maple syrup urine disease (MSUD). The two co-infecting viruses were hiding and triggering the underlying metabolic disorder. The genotyping of the viruses as well as the chronological course, wide spectra of laboratory tests and clinical presentations of this case which includes recurrent vomiting without diarrhoea, metabolic acidosis, unconsciousness, seizure and circulatory collapse, but with positive final outcome is also presented