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Two coxsackieviruses associated with generalized, atypical exanthema in HFMD
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Hand, foot and mouth disease can present with a range of clinical symptoms, but certain virus serotypes are associated with specific dermatological patterns, according to recent study findings published in The Pediatric Infectious Disease Journal.
Thomas Hubiche, MD, of Centre Hospitalier Intercommunal de Fréjus Saint-Raphaël in France, and colleagues evaluated 104 children aged 0 to 18 years (mean age, 25.7 months) from seven pediatric dermatology units from March 2010 to February 2012 to determine the dermatological pattern of hand, foot and mouth disease (HFMD) and the virus serotypes associated with specific dermatological patterns. Eighty-nine patients positive for human enterovirus infection made up the study population.
Thomas Hubiche
Skin lesions in the hand, foot and mouth regions were present in 66.3% of patients; however, lesions were present in other areas in 87.6% of patients. These areas were mostly on the buttocks (67.4%), legs (56.2%), arms (25.8%) and trunk (20.2%). Scalp lesions were not found on any patients. Five or more anatomical sites were involved among 41.5% of patients with confirmed HFMD and two sites were involved among 12.3% of patients with confirmed disease.
Vesicles were present in 96.6% of patients and 38.2% had papules or superficial crusts. Both vesicles and crusts were present among 34.8%. Eight patients had grouped vesicles, which were related to eczema coxsackium in two patients. Both of these patients had a medical history of atopic dermatitis and the vesicles were concentrated on atopic dermatitis bastion areas.
The remaining six patients did not have atopic dermatitis, and their skin lesions were concentrated outside of the classical atopic dermatitis bastion areas.
Overall, 16 patients were hospitalized; 10 because of low fluid intake associated with odynophagia (n=9) or vomiting (n=1); three because of poorly tolerated high fever; and one patient because of extensive skin lesions. Neurological signs were present in two patients.
Forty-two patients had serotype coxsackievirus (CV)-A6 identified and 28 patients had CV-A16. Five or more anatomical sites were involved in 41.6% of CV-A6–related cases and 46.4% of CV-A16–related cases. CV-A6 was more frequently associated with perioral dermatitis compared with CV-A16 infections (P<.001).
“HFMD is more likely a diffuse vesicular exanthema,” Hubiche told Infectious Diseases in Children. “In the generalized or atypical HFMD, the presence of skin lesions on two bastions (hand, foot, mouth) and the absence of lesion on the scale are strong arguments for the diagnosis of HFMD. Don't forget to tell parents that onychomadesis might occur from 2 to 3 weeks after the onset of the rash.” — by Amber Cox
Thomas Hubiche, MD, can be reached at hubiche-t-@chi-frejus-saint-raphael.fr.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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José R. Romero, MD
In 1958, the first report of the clinical findings of what would become known as HFMD was published. The enterovirus serotype CV-A16 was isolated from a high percentage of the patients. Over the next 5 years, multiple reports expanded and further defined the clinical spectrum of HFMD, as well as provided the first indication of its association with other enterovirus serotypes. Although at least 16 serotypes are known to cause HFMD, it is most frequently associated with CV-A16 and enterovirus (EV)-A71. Recently, reports have indicated that CV-A6–related HFMD has a wider distribution of skin lesions and may lead to a higher rate of hospitalization.
With their report, Hubiche and colleagues add to our understanding of the extent of the dermatologic involvement of HFMD. They show that the enanthem/exanthem of HFMD frequently involved more than the three sites (mouth, hands, feet) typically associated with the syndrome. In addition, they provide further information regarding the presentation of HFMD caused by CV-A6. In 89 children with EV-confirmed HFMD, predominantly due to CV-A6 (47%) or CV-A16 (31.5%), approximately 42% were found to have involvement of the skin or mucous membrane of five or more anatomic sites (mouth or perioral, hands, feet, buttocks, trunk, legs, arms). In only 12% of cases were the lesions limited to two skin or mucous membrane sites. Exanthems involving the perioral area occurred frequently in cases due to CV-A6 infection. Hospitalization, primarily the result of poor fluid intake, occurred in nearly 18% of cases. More than half of those hospitalized had CV-A6 infection. This report and accompanying photographs will be of interest to clinicians caring for children.
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