An 18-month-old girl with fever and vesiculopapular rash (Page 2/2)

Prepared by...
Kakanang Jantarapagdee, M.D.
Virat Sirisanthana, M.D.
Department of Pediatrics, Chiang Mai University, Thailand
Diagnosis: Hand-foot-and-mouth (HFM) disease
Discussion: This clearly recognizable syndrome is characterized by vesicular lesions on the anterior mouth and an exanthem on the hands and feet (and buttocks) in association with low grade fever. The patients have an excellent prognosis with full recovery.
> HFM disease is caused by a group of RNA viruses called enteroviruses. The most commonly implicated enterovirus is coxsackievirus A16.
> In 1997 there was an outbreak of HFM disease in Malaysia, causing unusual death in some children. The deadly causative agent was Enterovirus 71. After that there were several outbreaks in Southeast Asia due to this enterovirus 71. Thailand started runnung the outbreak surveillence in 2001. The results is shown below which indicates that there is still no no evidence of the outbreak in Thailand. (ref 1)
Characteristics:
> Cases are commonly spread via the fecal-oral or oral-oral route. Respiratory droplet transmission also may occur but is less likely.
> Age: less than 5 years
> The usual incubation period is 3-6 days.
> Prodrome
o Low-grade fever
o Malaise
o Anorexia
> The prodrome precedes the development of oral lesions, followed shortly by skin lesions, primarily on the hands and feet and occasionally on the buttocks.
> Oral cavity:
o Yellow ulcers surrounded by red halos
o These occur primarily on the labial and buccal mucosal surfaces, but they may be observed on the tongue, palate, uvula, anterior tonsillar pillars, or gums.
o The oral ulcers are usually only mildly painful. Children younger than 5 years are predominately more symptomatic than older patients.
> Hands and feet:
o The exanthem involves the palmar, plantar, and interdigital surfaces of the hands and feet.
o These lesions may be asymptomatic or pruritic.
o They usually begin as erythematous macules that rapidly progress to thick-walled grey vesicles with an erythematous base.
o In young infants, these lesions also may be observed on the trunk, thighs, and buttocks.
o The rash is usually self-limited, lasting approximately 3-6 days.
  Laboratory studies : usually are unnecessary.
• If clinical circumstances dictate, the virus can be recovered from the HFM lesions. Typically, the virus can be grown in culture or confirmed by immunologic methods
  Treatment : primarily supportive
• Antipyretics should be given as needed for fever.
• IV hydration should be given if the clinical assessment indicates.
  Prognosis:
• Patients have an excellent prognosis with full recovery except for Enterovirus 71 Hand-foot-mand-mouth disease


Enterovirus 71 Hand-foot-mand-mouth disease: should be suspected in cases with;
> High fever >39 degree celcious and
> Fever lasts longer then 3 days

The complications were found in 32% of cases of enterovirus 71 hand-foot-and-mouth disease compared to 6.3% in cases caused by Cox A16. These included: aseptic meningitis, encephalitis, polio like syndrome,encephalomyelitis, cerebellitis and pulmonary edema (neurogenic pulmonary edema). Most death were due to neurogenic pulmonary edema. ( ref 2)

References:
> http://epid.moph.go.th/dssur/contact/hfm.htm
>

ธนิกานต์ คีรีวิเชียร, ธันยวีร์ ภูธนกิจ. โรคมือเท้าปาก (Hand-foot-and mouth disease). Topic Review กันยายน พ.ศ. 2545 ภาควิชากุมารเวชศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ (click for pdf file )


BACK to Interesting  Case List