Identifying atypical presentations of hand-foot-and-mouth disease can improve patient care

Key takeaways:

• Coxsackievirus A6 was identified in 63% of atypical hand-foot-and-mouth disease cases.
• Most common atypical morphologies included vesicles (53%), papules (49%) and bullae (36%).

Atypical cutaneous manifestations of hand-foot-and-mouth disease may be associated with coxsackievirus A6 and often include the atypical distribution of vesicles, according to a study.

“Atypical cutaneous manifestations of [hand-foot-and-mouth disease (HFMD)], often associated with [coxsackievirus A6 (CVA6)], were first reported in 2008, and have subsequently been reported with increasing frequency worldwide,” Samantha Y. Starkey, MD, of the University of British Columbia and Nemours Children’s Hospital, Delaware, and colleagues wrote. “Although widely circulating in the community, CVA6 rarely attracted clinical attention as infections were typically mild or asymptomatic.”

To bring awareness to the presentation of atypical HFMD, Starkey and colleagues performed a systematic review of 85 studies that included 1,359 atypical HFMD cases.

Results showed that CVA6 was identified in 63% of the cases. The morphologies reported included vesicles (53%), papules (49%), bullae (36%), macules (20%), eczema herpeticum-like (19%), erosions (14%), purpuric/petechial (7%), crust (6%), mucosal ulcers (4%) and Gianotti Crosti-like (4%).

According to the authors, vesicular lesions tend to remain on the palms, soles and oral mucosa in typical cases. However, in atypical cases, vesicular lesions may be more widespread on the dorsal hands and feet, legs, arms, trunk and neck, with rare involvement of the oral mucosa.

The authors found that the most common atypical locations of various cutaneous manifestations were the arms or legs (47%) followed by the face (45%) and trunk (27%).

Similar to classic HFMD, 74% of atypical cases included fever as the most common symptom followed by 18% experiencing pharyngitis and 16% cough.

Nail complications, such as onychomadesis and Beau’s lines, and desquamation were found in 21% and 4% of atypical cases, respectively. Although these complications are consistent with typical HFMD cases, the authors reported that there is some evidence supporting higher rates of nail changes among atypical HFMD cases.

“HFMD should be considered in the differential diagnosis of patients with new-onset vesicles and erosions on eczematous areas, for acral purpura, and for a Gianotti-Crosti-like papulovesicular rash with prominent erosions,” the authors concluded.