Hand-foot-mouth disease B08.4

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

false foot-and-mouth disease; Foot-and-mouth disease false; hand foot mouth disease; Hand-foot-mouth-disease; Hand Foot Mouth Disease; hand foot mouth exanthema; Hand-foot-mouth exanthema; Hand-Mouth-Foot Disease

History
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Dalldorf and Sickles, 1948

Definition
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Epidemic, endemic and sporadic, usually mild, vesicular viral exanthema on palmae, plantae and oral mucosa. Most frequently in summer or autumn.

Pathogen
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Coxsackie viruses of group A16; more rarely A4, A5, A9, A10 (transmission by droplet infection or direct contact), echo or enteroviruses (enterovirus 71).

Manifestation
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Mostly occurring in children before the 10th LJ, rarely in adults.

Clinical features
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General: Incubation period 3-7 days, maximum 2 weeks. About 2 weeks of unspecific prodromies (fever, headache, rhinitis, gastrointestinal symptoms).

Oral mucosa: First visible symptoms are pinhead-sized intraoral erythema, which quickly turn into translucent vesicles; later yellowish-white, very painful aphthae. Abortive forms are possible.

Integument: Characteristic is a painful vesiculous exanthema on hands and feet, especially on palmae and plantae, with intermittent, disseminated, flat, angular papules which change into elongated, polygonal vesicles with a reddened courtyard, and later into pustules.

Rare papulo-vesicular (often overlooked) exanthema on the trunk and buttocks.

Besides the uncharacteristic prodromal symptoms, subfebrile temperatures and regional lymph node swelling are found. The concordant occurrence of subacute granulomatous thyroiditis de Quervain with hand-foot-mouth disease was described (Engkakul P et al. 2011).

Histology
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Depending on the stage of development (papules, vesicles or erosions) and localization (skin or mucosa) of the lesions, different histological images are found. Mostly evidence of spongiosis, dyskeratotic cells and giant cells. In the dermis uncharacteristic perivascular accentuated lymphocytic infiltrate.

Differential diagnosis
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Gingivostomatitis herpetica: First manifestation of a herpes simplex infection. Grouped vesicles intraorally, usually severe clinical picture.

Herpangina: Analogous clinical picture to hand-feet-mouth disease, but mostly without the changes on the integument.

Zoster: segmental infestation pattern. Children are an untypical age of manifestation

Varicella: disseminated (not localized) papulo-vesicular exanthema. Vesicles and pustules. Typical multiple efflorescence pattern (star map)

Aphthae: few lesions, no integumentary involvement (except Behçet's disease), chronic recurrent course.

Erythema exsudativum multiforme: typical cockade structure of the skin lesions (ring in ring), foci significantly larger, no pain

Therapy
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Inform the patient about benignity of the skin changes! In some patients the skin changes heal under symptomatic local therapy (e.g. cooling, glucocorticoid creams such as 0.1% triamcinolone cream, in case of blistering antiseptic compresses with quinolinol solution, e.g. Chinosol 1:1000) or octenidine. In case of persistence glucocorticoids may be applied systemically.

Progression/forecast
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Spontaneous healing usually within 8-12 days. Complications are rare. Onycholysis (onychomadesis) of finger and/or toenails is not entirely rare (probably a viral infection of the keratinocytes of the nail matrix). On average, 4-6 nails are detached. Spontaneous healing at 100%.

Note(s)
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Attempt of virus detection from fresh stool samples or vesicle contents, complement fixation reaction.

The name Coxsackie comes from the US city (near New York) where the first epidemic was described.

Literature
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  1. Bernier V et al (2001) Nail matrix arrest in the course of hand, foot and mouth disease. Eur J Pediatr 160: 649-651
  2. Chan KP et al (2003) Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore. Emerg Infect Dis 9: 78-85
  3. Dalldorf G, Sickles GM (1948) An unidentified, filtrable agent isolated from the feces of children with paralysis. Science 108: 61-62
  4. Engkakul P et al (2011) de Quervain thyroiditis in a young boy following hand-foot-mouth disease. Eur J Pediatr 170:527-529.
  5. Elsner P et al. (1985) Hand-foot-mouth disease. Dermatologist 36: 161-164
  6. Esposito S et al (2018) Hand, foot and mouth disease: current knowledge on clinical manifestations, epidemiology, aetiology and prevention. Eur J Clin Microbiol Infect Dis 37:391-398.
  7. Faulkner CF et al (2003) Hand, foot and mouth disease in an immunocompromised adult treated with aciclovir. Australas J Dermatol 44: 203-206
  8. Ho M et al (1999) An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group. N Engl J Med 341: 929-935
  9. Shieh WJ (2001) Pathologic studies of fatal cases in outbreak of hand, foot, and mouth disease, Taiwan. Emerg Infect Dis 7: 146-148
  10. Solomon T et al (2003) Exotic and emerging viral encephalitides. Curr Opin Neurol 16: 411-418
  11. Wang JR et al (2002) Change of major genotype of enterovirus 71 in outbreaks of hand-foot-and-mouth disease in Taiwan between 1998 and 2000 J Clin Microbiol 40: 10-15

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 29.10.2020