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2016 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer - Medknow 7
cases occur during summer and early autumn.[1,2] Inmost instances, this is a mild self-limiting illness. Theskin lesions heal spontaneously without scarring. Theanalysis of the recent epidemics has shown a spectrum
INTRODUCTION
Hand, foot, and mouth disease (HFMD), a viralinfection which predominantly affects thechildren is characterized by a brief prodrome anderythematous papulovesicles mostly localized to palmsand soles with or without oral ulcerations. Involvementof buttocks, knees, elbows, and perioral skin is foundless commonly.[1,2]HFMD is usually been associated
with coxsackie A16, not uncommonly by coxsackie
A5, A10, and by human enterovirus 71.[3]The most
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DOI:
10.4103/2319-7250.173150
Hand, foot and mouth disease in children: A clinico
epidemiological study
K Bhumesh Kumar, A Geeta Kiran, B Udaya KumarDepartment of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad, Telangana, India
ABSTRACT
Background:Epidemics of hand, foot, and mouth disease (HFMD) are increasing every year globally. The disease now
presents an increasing threat to public health worldwide. HFMD is a highly contagious viral infection characterized by a
typical maculopapular or vesicular eruptions on the hands and feet and in the oral cavity. It affects predominantly children
and/or immunocompromised adults and follows a benign self-limiting course. However, HFMD cases with severe or lethal
complications such as encephalitis, meningitis, pulmonary edema, and myocarditis have been reported mostly in children,
and also in immunocompromised adults. The common pathogens are coxsackievirus A16, enterovirus 71, and recently
coxsackieviruses A6 and A10 have been included. Differences in the course of HFMD have been observed depending on
the virus type, age, and immune status.
Aim:This study is to review the clinico epidemiological data for HFMD for early diagnosis and treatment, to prevent the
complications and to implement the precautionary measures during outbreaks.
Materials and Methods: A prospective observational study is conducted from August 2013 to January 2014. Consecutive
cases clinically diagnosed as HFMD, in the pediatric age group were taken up.
Results:We report the clinico epidemiological study of 50 cases of HFMD, their benign course and recovery among
immunocompetent children.
Conclusion: Early accurate diagnosis and treatment of HFMD along with monitoring is crucial to prevent severe
complications. Hence, a high index of suspicion is required to diagnose HFMD.
Key words: Coxsackievirus, hand, foot and mouth disease, immunocompetent children
ADDRESS FOR CORRESPONDENCEDr. K Bhumesh Kumar,
Department of Dermatology, Venereology and Leprosy, Gandhi MedicalCollege, Hyderabad - 500 003, Telangana, India.
E-mail: drbhumesh124@gmail.com
How to cite this article:Kumar K B, Kiran A G, Kumar B U. Hand, foot
and mouth disease in children: A clinico epidemiological study. Indian J
Paediatr Dermatol 2016;17:7-12.
This is an open access article distributed under the terms of the CreativeCommons Attribution-NonCommercial-ShareAlike 3.0 License, which allowsothers to remix, tweak, and build upon the work non-commercially, as long asthe author is credited and the new creations are licensed under the identicalterms.
For reprints contact: reprints@medknow.com
ORIGINAL ARTICLE
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Kumar, et al.: HFMD in children
Indian Journal of Paediatric Dermatology | Vol 17 | Issue 1 |Jan-Mar 20168
of central nervous system complications.[4]Mortalityis due to cardio-respiratory failure in severely affectedchildren.[5]
MATERIALS AND METHODS
A prospective observational study is conducted fromAugust 2013 to January 2014 in Hyderabad city.Consecutive cases clinically diagnosed as HFMD,in pediatric age group, attending DVL outpatientdepartment (OPD) were taken up.
Inclusion Criteria
All clinically diagnosed cases of HFMD children weretaken up for the study.
Exclusion Criteria
All above 18 years of age were excluded from thestudy.
Objectives
This study is to review the clinico epidemiologicaldata for HFMD for early diagnosis, to prevent thecomplications and to implement the precautionarymeasures during outbreaks.
RESULTS
A total of 50 cases were observed during an outbreakof HFMD. The youngest child among the casesstudied was 7-month-old and the oldest being
16 years [Chart 1]. The infection predominantlyaffected the children younger than 5 years (80%).Male to female ratio was 1:1. History of contact
with similar cases was found in 84% (42) ofcases [Chart 2]. All 50 cases presented with bothenanthemas and exanthemas either serially orsimultaneously, of which 44% (22) cases wereassociated with prodromal symptoms such as fever,irritability, etc. [Charts 3 and 4]. All the cases weremild in the form. There were no symptoms and signsof the primary immunodeficiency disorders such asrecurrent or atypical microbial infections, and they
were not on immunosuppressive medication.
Enathemas
Oral involvement [Figures 1 and 2] was found among48% (24) of 50 cases as a presenting complaint, of
which 70% (17) cases gave history of either droolingof saliva or refusal of feeds probably due to painfulerosions in infants. In seven cases (30%), painful oralerosions were seen on the soft palate, buccal mucosa,lateral side of the tongue, or on the dorsum of the
tongue in children [Chart 5]. Oral erosions were eithersingle or multiple in number.
Exanthemas
52% (26) cases presented with cutaneousmanifestations [Figures 3-5] as a presenting complaint
with itching and pain over the skin lesions in 6 and
2 cases, respectively. Remaining 70% (18) caseswere asymptomatic [Chart 6]. Exanthemas wereusually present in clusters of 310 maculopapules onerythematous skin involving the extremities either
80%(40)
20%(10)
0
10
20
30
40
Below 5 years Above 5 years
Chart 1:Predominantly affected age group is below 5 years (youngest age
was 7-month-old, and the oldest age was 16-year-old)
84%(42)
16%(8)0
10
20
30
40
50
History of contact No history of contact
Chart 2:History of contact with similar cases is seen in 42 (84%). No
history of contact in 8 (16%)
44%(22)
46%(28)
0
5
10
15
20
25
30
Prodromal symptoms No prodromal symptoms
Chart 3:22 cases (44%) were associated with prodromal symptoms like
fever and irritability. No prodromal symptoms in 28 (46%)
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48%(24)
52%(26)
Enanthem as presenting
complaint
Exanthem as presenting
complaint
Chart 4:All 50 cases presented with both enathemas and exanthemas
of 23 days duration. Presenting complaint as enanthem is 48% and as
exanthema is 52%Figure 1:Erosion on soft palate
Figure 2:Erosion on tongue
Figure 3:Football shaped vesicle on erythmatous base on palm and sole
Figure 4:On buttocks
Figure 5:Extensive involvement on trunk
on the hand or palm then spreading to other partsof the body such as buttocks, legs, arms, and trunk.The dorsal aspect of the hands and sides of the fingers
were involved more often than the palmar aspect andfeet.
The diagnosis of HFMD was made based ondetailed clinical history and examination. Routineinvestigations of complete blood profile, erythrocytesedimentation rate, C-reactive protein, complete
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urine examination and chest X-ray were normal.Tzanck smears were negative ruling out other viral
infections such as herpes simplex virus, varicella, andmeasles.
All the children were treated with supportiveand symptomatic therapy such as cold sponging,antipyretics, plenty of oral fluids along withreassurance and counseling their parents. The lesionssubsided in 710 days without any significantcomplications such as dehydration, encephalitis,meningitis, myocarditis, and pulmonary edema. Allcases were treated on OPD basis, and none of thepatients required hospitalization.
DISCUSSION
HFMD is also known as vesicular stomatitis withexanthema caused by coxsackievirus which is highlycontagious.[6]During epidemics, the virus spread byhorizontal transmission with an incubation periodof 36 days. Initially, viral implantation occurs inthe buccal and ileal mucosa followed by spread tothe lymph nodes within 24 h. Oral lesions begin aserythematous macules that evolve into 23 mm
vesicles on an erythematous base. The vesicles mayinvolve the palate, buccal mucosa, gingival, lips andtongue. The vesicles are rarely observed because theyrapidly become eroded. They are painful with droolingof saliva and may interfere with the masticationand feeding as it observed in our study, especiallyin infants. In 44% of cases, tongue involvement isreported.[7] Viremia rapidly ensues, with spread tothe oral mucosa and skin. All lesions will be clearedover a period of 12 weeks because after 710 days,neutralizing antibody levels increase and the virus iseliminated.[8]
The same was noted in our study in the form of clinicalclearance of lesions in 1 to 2 weeks.
Normally there is no enteric virus flora in a humanbeing. In an individual, only one type of enterovirusmultiplies within the intestine at any given point oftime. Polio vaccination has been eliminated poliovirusesfrom the gut, thereby increasing the chances of otherenteroviruses like coxsackievirus and echo viralinfections. It is possible that the emergence of HFMDin India may be related to the mass polio vaccination.[9]The largest outbreak of HFMD occurred in an easternpart of India in 2007, where about 38 cases of HFMDin and around Kolkata was reported.[10]
Complications such as dehydration,meningoenchephalitis, myocarditis, pulmonary edemaand death occasionally occur in children with HFMD.[11]Complications mainly depend on the strain of theorganism, age and immune status of the child. Out ofall complications, dehydration was the most common.It may be due to hyperpyrexia and refusal of feedingdue to painful erosions, it may be easily prevented byplenty of oral fluids, cold sponging, and antipyretics.In our study of HFMD, we could not find any majorcomplications since this outbreak may be caused bycoxsackievirus A16. It is a benign and most commonstrain whereas enterovirus 71 is a rare strain commonlyassociated with severe complications. Hence, earlydiagnosis and treatment along with monitoring forsevere complication is mandatory because clinically wemay not know the strain of the virus.
Oral lesions of HFMD can be easily misdiagnosed asaphthous ulcers, varicella or herpangina. However,aphthous ulcers are multiple, more painful andrecurrent not associated with prodromal symptoms.
70%(17) 30%(7)
0 10 20 30
Symptoms
sign
Chart 5: Enanthemas: History of excessive crying, drooling of saliva
and refusal of feeds is seen in infants in 17 cases (70%) whereas painful
erosions on the soft palate, buccal mucosa, lateral, dorsal and ventral side
of the tongue is seen in children in 7 cases (30%)
30%(8)
70%(18)
0
5
10
15
20
Symptomatic Asymptomatic
Chart 6:Exanthemas: Asymptomatic in 18 (70%) cases and symptomatic
in 8 cases (30%)
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Varicella rarely presents with oral lesions and theskin lesions are more concentrated on the trunk,rarely affecting the palms and soles. Herpangina isa viral infection of the children caused by a Type Acoxsackievirus which presents with similar types oforal ulcers extensively involving the tonsils, pharyngealmucosa, soft palate and the posterior part of buccal
mucosa.[12]Most of the parents come to us with thesuspicion of either measles or varicella infection.
Treatment
Medications are usually not needed as HFMD is a viraldisease that typically gets better on its own. Currently,there is no specific treatment for HFMD.[13] Diseasemanagement typically focuses on achieving symptomaticrelief. Pain from the sores may be eased with the useof analgesic medications like the topical application ofanesthetics and viscous lidocaine or dyphenhydramine.Infection in older children, adolescents, and adults is
typically mild and lasts approximately 1-week, but mayoccasionally run a longer course. Prodromal symptomslike fever can be treated with plenty of oral fluids, coldsponging, and antipyretics. A minority of individuals
with HFMD may require hospital admission due touncommon neurologic complications such as encephalitis,meningitis, or acute flaccid paralysis.[14]Nonneurologiccomplications such as myocarditis, pleural effusion, orbleeding into the lungs may also occur.[14]
Complications from the viral infections that causeHFMD are rare but require immediate medicaltreatment if present. HFMD infections caused byenterovirus 71 tend to be more severe and are more likelyto have neurologic or cardiac complications, includingdeath than infections caused by coxsackievirus
A16.[13] Viral or aseptic meningitis can occur withHFMD in rare cases and is characterized by fever,headache, stiff neck, or back pain.[13]The condition isusually mild and clears without treatment. However,hospitalization for a short time may be needed. Otherserious complications of HFMD include encephalitisor flaccid paralysis in rare circumstances.[13]
Fingernail and toenail loss have been reported in
children 48 weeks after having HFMD.[15] Therelationship between HFMD and the reported nailloss is unclear; however, it is temporary, and nailgrowth resumes without treatment.[15]
Prevention
Currently, there is no specific vaccine or antiviraltherapy against HFMD but such vaccines are beingdeveloped.[13] HFMD is highly contagious and istransmitted by nasopharyngeal secretions such as
saliva or nasal mucus, by direct contact, or by fecal-oraltransmission. Preventive measures include avoidingdirect contact with infected individuals, includingkeeping infected children home from school, propercleaning of shared utensils, disinfecting contaminatedsurfaces, and proper hand hygiene. These measureshave been shown to be effective in decreasing the
transmission of the viruses responsible for HFMD.[13]
CONCLUSION
Normally there is no enteric viral flora in human beings.Usually, only one type of enterovirus multiplies in anindividual at any given point of time. Polio vaccinationhas eliminated polio viruses from the gut therebyincreasing the chances of the coxsackievirus andenteroviral infections. It is possible that the emergenceof HFMD in India may be related to the mass polio
vaccination. Coxsackievirus A16 is more common and
has a benign course, whereas enerovirus 71 is rare andhas a lethal outcome. Early accurate diagnosis andtreatment of HFMD along with monitoring is crucialto prevent severe complications. Hence, a high indexof suspicion is required to diagnose HFMD.
Declaration of Patient Consent
The authors certify that they have obtained allappropriate patient consent forms. In the form thepatient(s) has/have given his/her/their consent for his/her/their images and other clinical information to bereported in the journal. The patients understand that
their names and initials will not be published anddue efforts will be made to conceal their identity, butanonymity cannot be guaranteed.
Financial Support and Sponsorship
Nil.
Conicts of Interest
There are no conflicts of interest.
REFERENCES
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2. Ang LW, Koh BK, Chan KP, Chua LT, James L, Goh KT.Epidemiology and control of hand, foot and mouth diseasein Singapore, 2001-2007. Ann Acad Med Singapore2009;38:106-12.
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4. Ho M, Chen ER, Hsu KH, Twu SJ, Chen KT, Tsai SF, et al.An epidemic of enterovirus 71 infection in Taiwan. Taiwan
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14. Li Y, Zhu R, Qian Y, Deng J. The characteristics of bloodglucose and WBC counts in peripheral blood of cases of handfoot and mouth disease in China: A systematic review. PLoSOne 2012;7:e29003.
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